Objective To introduce a case of elevated blood pressure with chills caused by Urinary Kallidinogenase.Methods The diagnosis and treatment of a patient with hypertension and chills induced by uracillin were analyzed retrospectively,and the correlation of adverse drug reactions(ADR)was analyzed The Chinese and English databases of CNKI,Vip,PubMed and Web of Science were searched to analyze the ADR case reports related to yurekline.Results The patient experienced a sudden increase in blood pressure with chills and sweats during the use of uracillin,and the adverse reaction was relieved gradually after withdrawal.According to Naranjo's ADR assessment scale and our manual of ADR reporting and monitoring,the association between uracillin and increased blood pressure with chills was"Probably".Conclusions The increase of blood pressure is a rare side effect of uracillin,so it is necessary to monitor the patients'blood pressure actively during the course of medication.Once the patients have the symptoms of blood pressure fluctuation,body shivering and mental abnormality,the clinic should judge and stop the medication in time to ensure the safety of the patients'medication.

Objective To introduce a case of elevated blood pressure with chills caused by Urinary Kallidinogenase.Methods The diagnosis and treatment of a patient with hypertension and chills induced by uracillin were analyzed retrospectively,and the correlation of adverse drug reactions(ADR)was analyzed The Chinese and English databases of CNKI,Vip,PubMed and Web of Science were searched to analyze the ADR case reports related to yurekline.Results The patient experienced a sudden increase in blood pressure with chills and sweats during the use of uracillin,and the adverse reaction was relieved gradually after withdrawal.According to Naranjo's ADR assessment scale and our manual of ADR reporting and monitoring,the association between uracillin and increased blood pressure with chills was"Probably".Conclusions The increase of blood pressure is a rare side effect of uracillin,so it is necessary to monitor the patients'blood pressure actively during the course of medication.Once the patients have the symptoms of blood pressure fluctuation,body shivering and mental abnormality,the clinic should judge and stop the medication in time to ensure the safety of the patients'medication.

ObjectiveTo elucidate the critical role of rehabilitation medical records (including electronic records) in rehabilitation medicine's clinical practice and management, comprehensively analyzed the structure, core content and data standards of rehabilitation medical records, to develop a standardized medical record data architecture and core dataset suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evaluation and payment. MethodsBased on the regulatory documents Basic Specifications for Medical Record Writing and Basic Specifications for Electronic Medical Records (Trial) issued by National Health Commission of China, and referencing the World Health Organization (WHO) Family of International Classifications (WHO-FICs) classifications, International Classification of Diseases (ICD-10/ICD-11), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), this study constructed the data architecture, core content and data standards for rehabilitation medical records. Furthermore, it explored the application of rehabilitation record summary sheets (home page) data in rehabilitation medical statistics and payment methods, including Diagnosis-related Groups (DRG), Diagnosis-Intervention Packet (DIP) and Case Mix Index. ResultsThis study proposed a systematic standard framework for rehabilitation medical records, covering key components such as patient demographics, rehabilitation diagnosis, functional assessment, rehabilitation treatment prescriptions, progress evaluations and discharge summaries. The research analyzed the systematic application methods and data standards of ICD-10/ICD-11, ICF and ICHI Beta-3 in the fields of medical record terminology, coding and assessment. Constructing a standardized data structure and data standards for rehabilitation medical records can significantly improve the quality of data reporting based on the medical record summary sheet, thereby enhancing the quality control of rehabilitation services, effectively supporting the optimization of rehabilitation medical insurance payment mechanisms, and contributing to the establishment of rehabilitation medical performance evaluation and payment based on DRG and DIP. ConclusionStructured rehabilitation records and data standardization are crucial tools for quality control in rehabilitation. Systematically applying the three reference classifications of the WHO-FICs, and aligning with national medical record and electronic health record specifications, facilitate the development of a standardized rehabilitation record architecture and core dataset. Standardizing rehabilitation care pathways based on the ICF methodology, and developing ICF- and ICD-11-based rehabilitation assessment tools, auxiliary diagnostic and therapeutic systems, and supporting terminology and coding systems, can effectively enhance the quality of rehabilitation records and enable interoperability and sharing of rehabilitation data with other medical data, ultimately improving the quality and safety of rehabilitation services.

ObjectiveTo explore the data standard system of electronic medical records in the field of rehabilitation, focusing on the terminology and coding standards, data structure, and key content categories of rehabilitation electronic medical records. MethodsBased on the Administrative Norms for the Application of Electronic Medical Records issued by the National Health Commission of China, the electronic medical record standard architecture issued by the International Organization for Standardization and Health Level Seven (HL7), the framework of the World Health Organization Family of International Classifications (WHO-FICs), Basic Architecture and Data Standards of Electronic Medical Records, Basic Data Set of Electronic Medical Records, and Specifications for Sharing Documents of Electronic Medical Records, the study constructed and organized the data structure, content, and data standards of rehabilitation electronic medical records. ResultsThe data structure of rehabilitation electronic medical records should strictly follow the structure of electronic medical records, including four levels (clinical document, document section, data set and data element) and four major content areas (basic information, diagnostic information, intervention information and cost information). Rehabilitation electronic medical records further integrated information related to rehabilitation needs and characteristics, emphasizing rehabilitation treatment, into clinical information. By fully applying the WHO-FICs reference classifications, rehabilitation electronic medical records could establish a standardized framework, diagnostic criteria, functional description tools, coding tools and terminology index tools for the coding, indexing, functional description, and analysis and interpretation of diseases and health problems. The study elaborated on the data structure and content categories of rehabilitation electronic medical records in four major categories, refined the granularity of reporting rehabilitation content in electronic medical records, and provided detailed data reporting guidance for rehabilitation electronic medical records. ConclusionThe standardization of rehabilitation electronic medical records is significant for improving the quality of rehabilitation medical services and promoting the rehabilitation process of patients. The development of rehabilitation electronic medical records must be based on the national and international standards. Under the general electronic medical records data structure and standards, a rehabilitation electronic medical records data system should be constructed which incorporates core data such as disease diagnosis, functional description and assessment, and rehabilitation interventions. The standardized rehabilitation electronic medical records scheme constructed in this study can support the improvement of standardization of rehabilitation electronic medical records data information.

ObjectiveTo analyze the data structure and standards of rehabilitation outpatient medical records, to provide data support for improving the quality of rehabilitation outpatient care and developing medical insurance payment policies. MethodsBased on the normative documents issued by the National Health Commission, Basic Standards for Medical Record Writing and Standards for Electronic Medical Record Sharing Documents, in accordance with the Quality Management Regulations for Outpatient (Emergency) Diagnosis and Treatment Information Pages (Trial), reference to the framework of the World Health Organization Family of International Classifications (WHO-FICs), the data framework and content of rehabilitation outpatient medical records were determined, and the data standards were discussed. ResultsThis study constructed a data framework for rehabilitation outpatient medical records, including four main components: patient basic information, visit process information, diagnosis and treatment information, and cost information. Three major reference classifications of WHO-FICs, International Classification of Diseases, International Classification of Functioning, Disability and Health, and International Classification of Health Interventions,were used to establish diagnostic standards and standardized terminology, as well as coding disease diagnosis, functional description, functional assessment, and rehabilitation interventions, to improve the quality of data reporting, and level of quality control in rehabilitation. ConclusionThe structuring and standardization of rehabilitation outpatient medical records are the foundation for sharing of rehabilitation data. The using of the three major classifications of WHO-FICs is valuable for the terminology and coding of disease diagnosis, functional description and assessment, and intervention in rehabilitation outpatient medical records, which is significant for sharing and interconnectivity of rehabilitation outpatient data, as well as for optimizing the quality and safety of rehabilitation medical services.

ObjectiveTo explore the standardization of inpatient rehabilitation medical record summary sheet, encompassing its structure, content and data standards, to enhance the standardization level of inpatient rehabilitation medical record summary sheet, improve data reporting quality, and provide accurate data support for medical insurance payment, hospital performance evaluation, and rehabilitation discipline evaluation. MethodsBased on the relevant specifications of the National Health Commission's Basic Norms for Medical Record Writing, Specifications for Sharing Documents of Electronic Medical Records, and Quality Management and Control Indicators for Inpatient Medical Record Summary Sheet (2016 Edition), this study analyzed the structure and content of the inpatient rehabilitation medical record summary sheet. The study systematically applied the three major reference classifications of the World Health Organization Family of International Classifications, International Classification of Diseases (ICD-10/ICD-11, ICD-9-CM-3), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), for disease diagnosis, functional description and assessment, and rehabilitation intervention, forming a standardized terminology system and coding methods. ResultsThe inpatient rehabilitation medical record summary sheet covered four major sections: inpatient information, hospitalization information, diagnosis and treatment information, and cost information. ICD-10/ICD-11 were the standards and coding tools for admission and discharge diagnoses in the inpatient rehabilitation medical record summary sheet. The three functional assessment tools recommended by ICD-11, the 36-item version of World Health Organization Disability Assessment Schedule 2.0, Brief Model Disability Survey and Generic Functioning domains, as well as ICF, were used for rehabilitation functioning assessment and the coding of outcomes. ICHI Beta-3 and ICD-9-CM-3 were used for coding surgical procedures and operations in the medical record summary sheet, and also for coding rehabilitation intervention items. ConclusionThe inpatient rehabilitation medical record summary sheet is a summary of the relevant content of the rehabilitation medical record and a tool for reporting inpatient rehabilitation data. It needs to be refined and optimized according to the characteristics of rehabilitation, with necessary data supplemented. The application of ICD-11/ICD-10, ICF and ICHI Beta-3/ICD-9-CM-3 classification standards would comprehensively promote the accuracy of inpatient diagnosis of diseases and functions. Based on ICD-11 and ICF, relevant functional assessment result data would be added, and ICHI Beta-3/ICD-9-CM-3 should be used to code rehabilitation interventions. Improving the quality of rehabilitation medical records and inpatient rehabilitation medical record summary sheet is an important part of rehabilitation quality control, and also lays an evidence-based data foundation for the analysis and application of inpatient rehabilitation medical record summary sheet.

A male patient,51 years old,was diagnosed as follows:① type 2 diabetes mellitus;② grade 2 hypertension(extremely high risk).To improve circulation,the patient was administered pentoxifylline injection 0.2 g mixed with 250 mL of 0.9％sodium chloride injection via an intravenous drip,once daily(qd).After 4 days of treatment,liver function tests showed the following results:alanine aminotransferase(ALT)at 2 390.80 U·L-1,aspartate aminotransferase(AST)at 948.28 U·L-1,and gamma-glutamyltransferase(GGT)at 517.81 U·L-1.It was highly probable that pentoxifylline caused abnormally elevated liver enzymes,with a clear drug-related association.After discontinuing pentoxifylline injection and initiating liver-protecting and en-zyme-lowering treatment,the liver function indicators gradually improved.Enhanced monitoring during the clinical use of pentoxi-fylline is essential to ensure patient safety.

A 70-year-old male patient with T2N2M0 stage Ⅲ A lung squamous cell carcinoma was switched to monotherapy with tislelizumab (200 mg by intravenous infusion on day 1, 21 days as a cycle) after 5 cycles of chemotherapy with paclitaxel protein-bound and cisplatin, one cycle of combined chemotherapy and immunotherapy with tislelizumab, paclitaxel protein-bound and cisplatin. After 10 days of tislelizumab administration in the 4th cycle of monotherapy, the patient developed symptoms such as nausea, vomiting, abdominal pain, and abdominal distension. Laboratory tests showed fasting blood glucose of 26.3 mmol/L, glycated hemoglobin of 12.5%, fasting C-peptide<0.01 μg/L, free triiodothyronine of 3.31 pmol/L, free thyroxine of 4.9 pmol/L, and thyroid stimulating hormone of 49.4 mU/L, urinary ketones (++), and urinary glucose (++). Ketoacidosis and hypothyroidism were diagnosed, which was considered to be caused by tislelizumab. After 7 days of treatments with insulin, fluid replacement, potassium supplementation, and maintenance of electrolytes and acid-base balance, the patient′s fasting blood glucose was 7.6 mmol/L. The hypoglycemic regimen was changed to subcutaneous injection insulin glargine (10 U in the morning) and insulin lispro (6 U before breakfast, 5 U before lunch and dinner), and levothyroxine sodium 100 μg once daily orally was given at the same time. Two weeks later, due to the condition, the patient received tislelizumab again once, and subsequently developed ketoacidosis 3 times. Tislelizumab was not used again thereafter. Follow-up once a month within 6 months showed no significant changes in the patient′s thyroid function compared to before. The patient continued to use insulin to control blood glucose.

A 66-year-old man was admitted with acute left heart failure and hyponatremia.On the first day of admission,15 mg tolvaptan tablets were given orally.On the second day of admission,alanine transaminase and aspartate transaminase were significantly increased to 916.76 U·L-1 and 1 857.1 U·L-1,respectively,which met the diagnostic criteria of severe acute liver injury.The drug was immediately stopped and hepatoprotective therapy was given,and on the 10th day of admission,the patient's liver function improved significantly,and on the 12th day of admission,the patient was discharged after his condition stabilised.The results of the correlation evaluation indicated that the development of acute liver injury in this patient is likely related to tolvaptan.This article discusses the mechanism,time of occurrence,population and treatment of tolvaptan-induced liver function injury,suggesting that clinical use of tolvaptan should be highly vigilant for acute liver function injury and routine monitoring of patients' liver function to ensure the safe use of the drug.

A 66-year-old man was admitted with acute left heart failure and hyponatremia.On the first day of admission,15 mg tolvaptan tablets were given orally.On the second day of admission,alanine transaminase and aspartate transaminase were significantly increased to 916.76 U·L-1 and 1 857.1 U·L-1,respectively,which met the diagnostic criteria of severe acute liver injury.The drug was immediately stopped and hepatoprotective therapy was given,and on the 10th day of admission,the patient's liver function improved significantly,and on the 12th day of admission,the patient was discharged after his condition stabilised.The results of the correlation evaluation indicated that the development of acute liver injury in this patient is likely related to tolvaptan.This article discusses the mechanism,time of occurrence,population and treatment of tolvaptan-induced liver function injury,suggesting that clinical use of tolvaptan should be highly vigilant for acute liver function injury and routine monitoring of patients' liver function to ensure the safe use of the drug.