Chapter 1745: 1685 The Medical Record Was Written Too Roughly

Zheng Lao Ban, please look at the lab report. The little doctor earnestly turned the iron medical record clip to where the lab report was attached, gave it to Zheng Ren, and then reported the medical history.

The patient came to our hospital 5 days ago with 4 hours of abdominal pain, was diagnosed with acute appendicitis, and underwent an appendectomy in the emergency department.

During the operation, the appendicitis showed atypical morphology; the appendix was successfully removed. Postoperatively, the patient still felt abdominal pain; several hours later abdominal distension appeared, but as it was tolerable, it was not given special attention. Afterwards, the distension gradually worsened while the pain gradually lessened.

Wait a moment, I saw during the operation that 20ML of pale yellow fluid was aspirated; did you assist in the Shou Bing? Zheng Ren did not look at the lab report directly, but instead found the Shou Bing record.

After a quick glance, Zheng Ren saw a sentence that made him doubtful.

Zheng Lao Ban, I assisted in the Shou Bing. The little doctor said: "When the peritoneum was cut during the Shou Bing, there was indeed a small amount of pale yellow fluid oozing out; I suctioned it clean with the Suction Device. There was no pus, and the fluid was relatively clear, not turbid."

He felt Zheng Ren was making a fuss over nothing; just a bit of fluid, possibly due to appendiceal exudate.

Although the fluid seemed considerable, it was estimated to be only 20ml, which didn't seem worth making a fuss over.

This is not the main point; the primary condition later is intestinal obstruction and a large amount of abdominal effusion.

But before he could finish reporting, Zheng Lao Ban interrupted him.

Hmm, let me think again, you continue. Zheng Ren said while flipping through the medical record.

An abdominal flat film showed intestinal obstruction. Accordingly, the patient was given nothing by mouth, continuous gastrointestinal decompression, and fluid replacement. 3 days after the operation, the patient passed gas and had bowel movements, but the abdominal distension continued to worsen, and there was obvious abdominal bulging. After a consultation with the chief, it was recommended that the patient's family transfer him to the Provincial Hospital for further diagnosis and treatment.

On examination, the patient was conscious but in poor spirits, with stable vital signs. Tenderness in the left lower abdomen was positive, no rebound pain, Murphy's sign negative, liver and spleen not palpable below the rib cage, no masses palpated in the abdomen, tenderness at the ureteric points absent, no tenderness in the liver and kidney area on percussion, abdominal dullness on percussion, shifting dullness positive, bowel sounds present normally at about 4 times per minute.

The little doctor felt somewhat pleased, having recited these things off the cuff, having put in a lot of effort.

A conscientious clinical doctor like this is hard to find even with a lantern.

With a shudder of his burly frame, Zheng Lao Ban almost kowtowed, crying and shouting that he wanted to take himself to Di Du.

It is said that the pusillanimous Liu Xu zhi from the Radiology Department had been invited many times by Zheng Lao Ban to work in Di Du; not only that, but there was also an establishment position.

That is an establishment position in Di Du.

If Liu Xu zhi can go, what can't I?

After reporting the medical history, the little doctor felt a bit pleased with himself.

Past medical history… Li Yong, has your spouse ever had hepatitis B or tuberculosis? Zheng Ren asked.

No.

The little doctor was puzzled; past medical history isn't important. It's all in the past—what's there to pursue?

Hepatitis B and tuberculosis have nothing to do with appendicitis, right?

Even if it were tuberculous intestinal obstruction, how rare would that be? Zheng Lao Ban is just splitting hairs—is he picking on me just because I reported the medical history well?

Have you undergone any Shou Bing? Zheng Ren continued to ask.

The little doctor looked bewildered at Li Yong.

"No……" Li Yong hesitated a bit.

Think again—procedures like a cesarean section count. Zheng Ren looked at the medical record, which hardly mentioned anything about the past history, feeling helpless.

The medical record was written too roughly, worse than Chang Yue by eighteen blocks.

Then I'll do it myself," Zheng Ren inquired.

I haven't had a cesarean section… I heard my spouse say that, before marriage… about 20 years ago, I underwent a Shou Bing; there was a mass on the bladder, which after removal was diagnosed as a benign lump. Li Yong searched in the dust of his memory for what Zheng Ren needed.

When taking the medical history from the patient's family, it's like this: many things the family doesn't pay attention to, thinking they're unrelated to the current condition; secondly, they simply forgot, which is a kind of memory bias.

Only by following clues and probing thoroughly can one possibly clarify the medical history.

Seeing patients is like solving a case; it's really not easy.

The bladder? Zheng Ren mused, "Let me take a look at the film."

The little doctor responded crisply, placing the upright abdominal flat film onto the viewer.

The film is simple, showing a fluid level; just by looking at the film, diagnosing intestinal obstruction presents no problem.

But intestinal obstruction…… abdominal effusion……

These two conditions have no necessary connection.

Zheng Ren went back and reviewed the medical orders again; for a large amount of abdominal effusion, the General Surgery Department of the People's Hospital in Xilin Town uses routine diuretic measures.

But the urine output recorded in the medical record is very low.

Is the urine output value recorded in the medical record correct? Zheng Ren asked.

Sometimes some doctors overlook this point and casually write down a number.

Zheng Lao Ban, I take my work very seriously. The little doctor's face flushed a bit; he felt wronged about that past medical history section.

This is clearly the patient's family's fault; I asked, but they said nothing. How come Zheng Lao Ban gets an answer just by asking?

That old bastard Li Yong, always putting eye drops on me!

Hmm, it can be seen. Zheng Ren said gently.

The little doctor's face improved a little.

But clinical experience is still not rich enough.

……

You used 40mg of furosemide, yet the urine output didn't increase, and renal function is fine—what are you considering? Zheng Ren asked.

"……" The little doctor stared for a moment, "I noticed this, so I advised the patient's family to take the patient to the Provincial Hospital."

Zheng Ren already had a guess; he smiled and said, "Come on, let's take a look at the patient."

Both the little doctor and Li Yong were drenched in sweat, but examining the patient and performing a physical exam are normal clinical procedures; the specific diagnosis should come out after seeing the patient.

If Zheng Lao Ban could understand it.

If he couldn't understand it…… that possibility is also quite large.

The little doctor led Zheng Ren to the ward ahead, hearing Zheng Ren ask: "What about the director?"

There's a luncheon at noon; they went out to eat.

"You want to drink again?" Zheng Ren asked.

"I guess." The junior doctor also had no choice; his department head liked to drink, and on his days off he would drink too. On normal workdays, when there was no Shou Bing in the Afternoon, he was also willing to have a couple of drinks—this was rather suspicious.

However, at a town-level Hospital, this kind of conduct is pretty much the same for everyone.

Upon entering the ward, the junior doctor stood respectfully to one side, watching Zheng Lao Ban conduct a physical exam.

He first glanced, and the abdomen was distended.

Hmm, this is the most basic visual inspection. Although he didn't say anything, after looking for nearly two seconds, he probably already started pondering the relevant condition in his mind.

Palpation—something he does three to five times a day—and the patient's painful spot actually shifted to the lower left abdomen.