2022年儿科英文病历 .pdf

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1、Medical Records for Admisson Medical Number: 696235 General information Name: Zhang Yi Age: thirteen Sex: FemaleRace:Han Nationality: China Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang Hesheng Mother Yang ChiulianDate of admission: May 8th, 20

2、01 Date of record: 11Am, May 8th, 2001 Complainer of history: patients mother Reliability: Reliable Chief complaint: Pharyngalgia and fever for four days. Present illness: The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found

3、 ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Childrens Hospital, there she received treatment of antibiotics, but her symptoms didn t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of

4、unknown” Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal. Past history The patient is healthy before. No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy

5、history of food but she was allergy to sulfa. Personal history 1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding. 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - -

6、- - 第 1 页，共 4 页 - - - - - - - - - 2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal. 3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned fro

7、m the breast at 14th month. 4.Immunization: Inoculated on schedule after birth (such as B.C.G , D.P.T and smallpox voccination). Physical examination T 39.5, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyano

8、sis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Head Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness. Ear: Bilateral auricles

9、were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses. Eye: Bilateral ey

10、elids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. Mouth: Oral mucous mem

11、brane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline. 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - -

12、- - - - 第 2 页，共 4 页 - - - - - - - - - Chest Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally. Lungs: Respiratory movement was bilateral

13、ly symmetric with the frequency of 30/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordi

14、al area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 120/min. Cardiac rhythm was regular. No pathological murmurs. Abdo

15、men: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No masses

16、. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs. Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exaned Investi

17、gation Impression: Fever of Unkown Acute Lymphocyte leukaemia? 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 3 页，共 4 页 - - - - - - - - - Signature: He Lin (95-10033) 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 4 页，共 4 页 - - - - - - - - -