Chief complaint: cough for 3 days and fever 1 day.
Medical history: The patient felt stuffy nose, runny nose and slight cough 3 days ago, and the effect of taking anti-cold medicine was not good. He has a cold and fever for nearly 1 day, and his temperature is 37.7℃. So he came to our hospital for treatment.
Examination: The patient is awake, the pharynx is red and swollen, the tonsil (-) lung is clear, and there is no abnormality in heart auscultation and abdominal examination. White blood cells are normal, and L is slightly higher. In (-).
Treatment: ribavirin 5 tablets/time, 3 times/day; VC Yinqiao tablets 3 tablets/time, 3 times/day; Isatis indigotica 15g/ time, 3 times/day; Compound Bulbus Fritillariae Cirrhosae tablets 4 tablets/time, 3 times/day; Nimesulide 1 tablet/for fever.
Diagnosis: upper respiratory tract infection (cold)
Question 2: How to write the medical record of cold and fever?
Sports:
Body temperature: 38 degrees Celsius
Fever face, conscious, obvious pharyngeal congestion, no tonsillar enlargement.
Heart rate: 38 beats/min, regular and clear breathing sounds, no obvious rales in both lungs.
Diagnosis:
1. What is the cause of fever?
2. Caught a cold.
Handling:
Routine blood examination.
Antivirus, symptomatic treatment.
r:
1. antiviral oral liquid 10ml orally, three times a day.
2. Nimesulide dispersible tablets 0. 1 orally, twice a day.
follow-up action
Doctor's signature
date
Question 3: Fill in the chief complaint of patients with cold and fever: cough, expectoration, high fever and fatigue for 2 days.
Physical examination:, the rhythm is 95bpm, the rhythm is regular, the body temperature is 39.65438 0℃, and the blood pressure is 1 10/70mmHg.
Heart auscultation: Breathing sounds in both lungs are thick and not obvious.
The onset comes from poor appetite, poor spirit, defecation and night sleep.
Diagnosis: Acute upper respiratory tract infection
Rx:
1.5% GNS 500ml
Penicillin 320U/vgtt Bid *3d (skin test)
2. Tylenol 2 boxes/1#tid po
Please come back at any time if you feel unwell.
Question 4: The doctor didn't see the patient for 20 minutes in the medical records of the fever clinic. Who will prescribe the medicine? That is to say, fever, many diseases can cause fever. Go to the hospital!
Question 5: How to write the cold medical record: dizziness, cough for 3 days, no discomfort such as fever, sore throat, less phlegm and white phlegm.
Pe: t 36.2 degrees, mild congestion in pharynx, no swelling in tonsils, clear breathing sounds in both lungs, no dry and wet rales,
I don't see anything unusual
Initial diagnosis: upper respiratory tract infection
R blood routine
Chest x-ray examination
Azithromycin 0.5qd
Compound licorice tablets 3 tablets, three times a day.
Vitamin C Yinqiao tablets 2 tablets, three times a day.
Pay attention to rest and drink plenty of water.