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Bản mô tả được viết theo thứ tự thời gian bao gồm những than phiền ban đầu của bệnh nhân (lý do nhập viện), và bệnh sử, những phát hiện lâm sàng của bác sĩ, kết quả của các xét nghiệm và thủ thuật chẩn đoán, và những thuốc và/hoặc thủ thuật dùng để điều trị.

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