Internship Note Six

Internship Note Six

I finished my doctor's order in the morning. The consultation form needs to be typed out to get the patient to do it. To 29 bed change dressing, and then take 40 bed to do gastroscopy (write the course time remember to write into the consultation results). Urine to make 2nd number of such as the hospital home-made preparations, need to establish a temporary medical advice to take medicine, and then a long-term medical advice to give a self-presentation daily distribution. Rehydration 500ml, is 500ml gns,34 bed booster treatment.

Anti-infection, tacrolimus FK506, immunosuppressant, non-bu he, uric acid. He's got a little mixed up! TM (He, free)

The third week, before whether or not I copy the Doctor's advice, I copy the next day, record the situation. Feeling can gradually to the patient's impression becomes deep, can recall the bed number remembers the patient long what kind, before prescribe what prescription. Of course, the shift is not ripe, you have to hurry to ask before the end of tomorrow.

Monday morning shift, go to the six floor listening. Mainly, yesterday, a few new patients, a few. The old patient condition, the patient's present medical history has the representative to say, then uses what the front treatment, the indicator symptom how, now what treatment, the symptom how. Does the new patient want to be specific about each?

Combined with a small book Recall memories:
59 edema normal, blood sugar slightly high, in the morning added 2 units, the current blood pressure with losartan, the pressure 150 down 50, so today added a luodingxin 10mg QD
29 bed old man, tube, constipation a week, less urine, opened a urine poison to 2nd, before the Lung infection Oncology consultation results did not come out
31 bed this afternoon, a left-handed arteriovenous prosthesis was reconstructed.
30-Bed is puncture number 21st? Building, previous hospital records I wrote
45 Bed Chiang Still wound pain, I do not know can do long-term tube, see what indicators?
44-bed hormones have changed their clothes.
42 beds are expected to be discharged the day after tomorrow.
41 bed Sichuan Boy in front of the 24h blood pressure monitoring, found high blood pressure, added luodingxin 5mg QD, the specific treatment plan to see how Wang Dean, is a fsgs, as if the prognosis is not very good.
40 bed morning gastroscope isolated to no ulcer, before OB negative, but hemoglobin drop fast, as if fungal infection. In the afternoon, a deep vein puncture catheterization (around 1.5cm on the inside of the artery), with a teacher in hospital, with a slightly shaken hands!
The 37 bed is a gout.
34 Bed low blood pressure, what's the punch? Today's appetite improvement, last night urine 2 times, 3 times a day, to ask the ultrafiltration volume
32 before the internal fistula, ckd4~5 period, the night before yesterday's blood 2h, blood before the first insulin is not halved, the results are very weak


Before noon asked a medical history, recalled the idea of a medical history. The bracketed content is now replenished.

Core: Spread around the main complaint, ask the key hormones, immunosuppression and other treatment, pay attention to kidney wear or not, pay attention to the urine protein creatinine and other indicators changes before and after treatment, the symptoms of relief or not, control situation.

What is the reason for hospitalization? High urinary protein
How long has it been? There was a period of no review, one months before the review found
Are there any symptoms, no edema, no urine foam urine (hematuria)? Weak
When did you first start to have this disease? 2012, when foot swelling, Ruijin hospital looked, did kidney wear, IgA nephropathy, CKD3 period
Can you look at the discharge summary at that time?
What was creatinine and 24h urine protein? More than 200, 9 Queudot
What medicine did you take at that time? 7 Hormones
Is there any other medicine that you remember clearly? In the discharge summary, there
(The discharge summary, check list) used Tacrolimus (3mg q12h)? Yes
Does urinary protein turn cloudy? Always
How's the edema? It's always been a little swollen.
Is it a little swollen now? Yes
How's the recent urine protein and creatinine? May 23, 24h urine protein 3.29, creatinine 233
Which means creatinine is more than 200 from the past 130 to now? Yes, it has been around 200, at least 130 more.
(Renal pathology, is a fsgs)
Have you had a cold lately? No
(start to ask the general situation, Shinqing Spirit soft)
How often do you urinate (do you have frequent urination and painful urination)? Normal, just a little urine.
Do you pee much at night? Normal
How about the number of stools? Is the texture normal? Normal
How's your appetite?
Have you had any changes in weight over the years? No
How's sleep? Yes, just a lot of dreams, more weak
Are there any other symptoms, such as joint pain, rash? Knee Pain
When did that hurt? How does that hurt? One months ago, sore
(Start asking past history, personal history)
Have you had surgery or blood transfusion? No
or trauma? No
Are there any infectious diseases like hepatitis? No
(Are there high blood pressure, heart disease, diabetes)?
Where was your birthplace? Where is the long-term residence? (to ask the county)
Career Hobby? ）
When did you get married? 23 years old
(Female: Early flow, menstruation, volume, pain, rule, duration, period)
How old is the child now? Older son 17, youngest son 9
Do parents have any diabetic hypertension or something like that? Father is ok, mother hypertension, coronary heart disease
Brothers and sisters (a few), are you in good health?
---------------
Then asked for the previous information, two Ruijin hospital discharge summary, outpatient medical records, and 12 to the present examination sheet (one centimeter thick). Found last year began to come to the city of outpatient, and then no longer after the end of treatment. There was a check list 1 months ago. So he went on to ask:
---------------
Did you come here last March to see it? What's the reason for coming here? How's the control in Shanghai? Yes. At that time, Western medicine has been controlled, I think Chinese medicine can be optimistic, a friend said Chen is better ...
A friend introduce you to the Director Chen? Yes
Then I see you do not have a check at the end of the year, is not after the visit? Yes, at that time to eat the Chinese medicine, the feeling is almost control the indicator, and then did not go to see again, I eat their own Western medicine.
(What kind of medicine do you take?) ）
Then last month to review what is the reason, edema or what? No, it's been a long time since I wanted to review.
What's the reason for your hospitalization? Is the indicator too high? Yes. Advise me to stay in hospital.

---------------
Ask questions tomorrow, take a look:
Essential hypertension
Causes: Heredity, environment (diet, spirit), weight, medicine, SAHS;
Pathogenesis: hyperactivity; renal sodium retention; Raas system activation; membrane ion transport abnormalities (calcium pump reduction, potassium and sodium defects, membrane permeability enhancement); insulin resistance
Diagnostics: 140/90,2 level 160 100 3 level 180 110
Principles of Treatment: Improve life behavior: control of salt fat tobacco wine, exercise, weight, potassium supplementation calcium, 2 or more or with diabetes complications, can not be controlled by life behavior, antihypertensive treatment. Control to 140/90, complication 130/80, senile 140~150, diastolic pressure 65~70 to 90
Drug:
Diuretics: Pyrazine, loop diuretics and potassium-preserving diuretic, gout disabled, mild to moderate, potassium-preserving is not suitable for aceiarb, renal insufficiency with a loop diuretic
Betablocker:beta1 Beta12 Alpha, Rockwell. By inhibiting Raas and central, hemodynamic, strong and rapid, lower heart rate, insulin resistance, cover hypoglycemia, asthma is disabled
CCB: Divided into two pyridine and non-two pyridine class, the former with Nifedipine as the representative, the latter has verapamil and diltiazem. Accelerate heart rate, facial red, lower limb edema. Anti-As
ACEI: Ripley. Improves insulin resistance and reduces proteinuria. Dry cough.
ARB: Losartan.
Others include: cross-feeling inhibition: blood level, clonidine; dilation: alpha1 block: piperazine (side effects, often compound)
Complication of Buck:
Cerebrovascular: ARB ACEI CCB diuretic
Coronary heart disease: stable angina pectoris: BB ACEI CCB Heart Terrier: BB ACEI prevents ventricular remodeling, as long as possible
Heart failure: Asymptomatic BB ACEI, symptomatic ACEI diuretic or arb BB
Slow kidney failure: Three kinds of treatment, early acei ARB, but can lead to deterioration of renal function in the late stage
Diabetes: 1 type Kidney before the problem of normal blood pressure, type 2 earlier with high blood pressure. More than 2 kinds of drugs. ARB ACEI CCB small dose diuretics. ACEI arb slows down the progression of sugar and kidney
Refractory hypertension (to be seen)

6.27

Internship Note Six