How to analyze and diagnose medical records of doctors in Zhongshan Eye Hospital
Zhongshan Eye Hospital is a professional eye hospital with a high-quality expert team and superb medical technology. In terms of medical record analysis and diagnosis, doctors have formed a unique set of methods after years of practice and experience. The following will elaborate on how doctors of Zhongshan Eye Hospital analyze and diagnose medical records from four aspects: medical history collection, examination, auxiliary examination and diagnosis.
history taking
The collection of medical history is the first step in the analysis and diagnosis of medical records. The doctor will make detailed inquiries with the patient to understand the patient's chief complaint, illness changes, medical experience and other information. First, doctors will ask patients about their symptoms, onset time and development, so as to preliminarily determine the possibility of the disease. Then, the doctor will know the patient's family history, allergy history and other relevant medical history, so as to comprehensively consider the possible causes. Finally, the doctor will also ask the patient about his/her personal lifestyle and working environment, so as to provide reference for subsequent auxiliary examinations.
Next, the doctor will conduct a comprehensive physical examination to further determine the condition. First, the doctor will observe the patient's face, eyes and periocular area to see if there are swelling, redness, bleeding and other symptoms. Then, the doctor will perform routine examinations such as vision, pupil, eye movement, intraocular pressure, etc. to evaluate the eye condition. In addition, the doctor will also check the patient's fundus, ocular surface, cornea, sclera, etc. to understand possible lesions.
Auxiliary examination is an important part of medical record analysis and diagnosis, which can provide doctors with more disease information and diagnosis basis. Zhongshan Eye Hospital is equipped with advanced examination equipment, which can carry out various ophthalmic auxiliary examinations. For example, fundus fluorescein angiography can observe the development of fundus blood vessels, which has a good auxiliary effect on retinopathy. In addition, visual field examination, electrooculogram, photocoagulation and other auxiliary examinations also provide doctors with more information. The doctor will select appropriate auxiliary examination methods according to the specific situation of the patient, and make a comprehensive judgment based on other examination results.
diagnosis
Through the above medical history collection, examination and auxiliary examination, the doctor can preliminarily judge the possibility of the patient's eye disease. Then, doctors will further analyze and diagnose the condition according to clinical experience and professional knowledge. Doctors will make differential diagnosis according to the symptoms, signs and examination results of patients, combined with the characteristics of common ophthalmic diseases.
In the process of diagnosis, doctors need to consider the relationship between different ophthalmic diseases, especially the possible complications and coexisting diseases of some diseases. Doctors also need to make comprehensive assessment and judgment based on the patient's age, gender, basic diseases and other factors. After an eye disease is diagnosed, the doctor will explain the nature, treatment plan and prognosis of the disease to the patient and provide personalized treatment suggestions.
Summary
In general, doctors in Zhongshan Eye Hospital will conduct comprehensive medical history collection, careful inspection and accurate auxiliary inspection when conducting medical record analysis and diagnosis. Through clinical experience and professional knowledge, doctors conduct in-depth analysis and diagnosis of the condition, and provide accurate diagnosis results and personalized treatment plans for patients.
Zhongshan Eye Hospital, with its excellent medical team and advanced equipment, provides patients with high-quality ophthalmic medical services. Whether it is medical record analysis or diagnosis, doctors always adhere to the principle of scientific, accurate, comprehensive and meticulous to provide the best medical effect and help patients regain a bright vision.
