Generally speaking, the first page of a case book has its own established format, which varies from place to place. Usually write your name and age on the cover.

Kidney calculi cases such as:

2008-08-08

Main statement: the pain in the left waist lasts for 5 hours.

Current medical history: The patient complained of sudden pain and tingling in the left waist five hours ago, which could not be relieved after exercise and bed rest, accompanied by sweating.

Past history, personal history, family history: nothing special.

Auxiliary examination: B-ultrasound showed multiple stones in the left kidney. Urine Rt: red blood cells (++)

Diagnosis: Multiple stones in the left kidney.

Processing: 1. Drink more water. 2。 Cefotaxime 0.2 Doctor's signature: XXX

Guiding opinions:

You can say that there are two small stones, one is 0.2mmX0.2mm and the other is 0.5mmX0.4mm, so drinking water of this size can generally be discharged by itself. At the same time, oral antibiotics are enough.