@hailin-zheng/editor-core 1.0.6 → 1.0.9

package/src/med_editor//347/227/205/347/250/213/345/275/225//351/246/226/346/254/241/344/270/212/347/272/247/345/214/273/345/270/210/346/237/245/346/210/277/350/256/260/345/275/225.json

@@ -0,0 +1,272 @@
+{
+    "type": "doc",
+    "props": {
+        "width": 210,
+        "height": 297,
+        "padding": {
+            "top": 25.4,
+            "bottom": 25.4,
+            "left": 19.1,
+            "right": 19.1
+        },
+        "headerLine": 12,
+        "footerLine": 12
+    },
+    "children": [
+        {
+            "type": "header",
+            "children": [
+                {
+                    "type": "p",
+                    "props": {
+                        "textAlign": "center"
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "content": "首次上级医生查房记录"
+                        }
+                    ]
+                }
+            ]
+        },
+        {
+            "type": "body",
+            "children": [
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "记录时间：2022-02-28 10:31"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "病史特点："
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "1、患者陈帮梅，女，57岁"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "2、因“纳差、腹胀、早饱1月”入院。"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "3、既往有子宫切除术，有输卵管结扎手术史20年，2年前曾因“右侧颈动脉狭窄行手术治疗”余无特殊，否认肝炎、结核，糖尿病病史及其他病史，否认药物，食物过敏史，否认外伤、输血史，预防接种史不详。居住地14天内无疑似及确诊病例，近期无确诊病人及疑似病人接触史，未接触有发热或呼吸道症状人员"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "4、查体：T 36.5 ℃，P 67 次/分，R 18 次/分，BP 160/85 mmHg，神志清楚，营养中等、步入病区，查体合作，皮肤及巩膜无黄染及出血点，浅表淋巴结无肿大，颈软，右侧颈部见一陈旧性手术瘢痕，双肺呼吸音清晰，未闻及干、湿性啰音，心率约67次/分，律齐，心音有力，各瓣膜听诊区未闻及病理性杂音，腹平软，上腹部剑突下区轻度压痛，无肌紧张、无反跳痛，未触及包块，肝脾肋缘下未触及，双肾区无叩击痛，肠鸣音约3次/分。下腹正中见一纵行手术瘢痕，脊柱四肢无明显异常。双下肢无水肿。生理反射正常，病理反射未引出。"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "5、辅助检查：[我院2020年9月04胃镜示：慢性浅表性胃炎伴糜烂，胃多发息肉，巴雷特食管。慢性食管炎。心电图示：窦性心律，正常范围心电图。]胸部CT：右肺少许增殖纤维灶。主动脉及冠状动脉粥样硬化。新冠病毒2019-nCoV核酸未检出,新型冠状病毒抗体IgG阴性,新型冠状病毒抗体IgM阴性,肝肾糖脂电解质心肌酶未见异常。,乙肝病毒表面抗原阳性S/CO新冠病毒2019-nCoV核酸未检出,新型冠状病毒抗体IgG阴性,新型冠状病毒抗体IgM阴性,肝肾糖脂电解质心肌酶未见异常。,乙肝病毒表面抗原阳性S/CO，血凝、肿标未见异常]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "诊断：[1.慢性浅表性胃炎 2.胃息肉 3.巴雷特食管 4.慢性食管炎 5.睡眠障碍]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "诊断依据：[1.慢性浅表性胃炎伴糜烂 2.胃息肉 3.巴雷特食管 4.慢性食管炎 ：57岁女性患者，有腹胀、早饱症状；查体上腹轻压痛。胃镜检查见：我院2020年9月04胃镜示：慢性浅表性胃炎伴糜烂，胃多发息肉，巴雷特食管。慢性食管炎。故诊断。5.睡眠障碍  患者长期睡眠差，多醒，睡眠治疗差，故诊断。]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "鉴别诊断：[1.胃/十二指肠溃疡 57岁女性患者，因“纳差、腹胀、早饱1月”入院，需与胃十二指肠溃疡引起的疼痛相鉴别，但患者疼痛无明显规律性，且门诊电子胃镜结果不支持，故考虑本病可能性小，暂除外。    2.胃癌？ 57岁女性患者，因“纳差、腹胀、早饱1月”入院，需警惕存在胃癌可能，但胃癌既往大多有胃溃疡病史，本病患者不符，且电子胃镜检查结果不支持，暂除外。]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "诊疗计划：[ 1、完善相关检查（C-14呼气试验等）。    2、予抑酸、护胃及对症支持治疗，择期行胃镜下治疗。]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "预后:[能积极配合治疗，估计近期预后尚可]"
+                        }
+                    ]
+                },
+                {
+                    "type": "p",
+                    "props": {
+                        "textAlign": "right",
+                        "textProps": {
+                            "fontSize": 16
+                        }
+                    },
+                    "children": [
+                        {
+                            "type": "text",
+                            "props": {
+                                "fontSize": 16
+                            },
+                            "content": "医生签名:[胡筠]记录医生签名：[刘泽兴]"
+                        }
+                    ]
+                }
+            ]
+        },
+        {
+            "type": "footer",
+            "children": [
+                {
+                    "type": "p"
+                }
+            ]
+        },
+        {
+            "type": "comm-list"
+        }
+    ]
+}