川崎病,冠状动脉扩张.doc

*Error! Picture switch must be first formatting switch.入院记录Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.姓名：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.陈钰捷Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.家长姓名：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.陈伟荣Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.性别：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.男Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.联系电话：Error! Picture switch must be first formatting switch.Error! 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Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*主治医师签名： 日期：*Error! Picture switch must be first formatting switch.补充诊断：Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.请输入诊断内容Error! Picture switch must be first formatting switch.* 签名： 日期：*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.1.主诉：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.发热1月余，咳嗽7天。Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.2.现病史：Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.科室现病史Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.患儿1月余前出现发热，体温最高39.5，热时无惊厥、抽搐，伴有背部红色皮疹，结膜充血，杨梅舌，无手足硬肿，入院外院治疗考虑不完全川崎病，予以大剂量丙种球蛋白Error! Picture switch must be first formatting switch.抗炎，甲强龙抗炎，阿司匹林、潘生丁抗凝至今，患儿体温反复，并出现手指脱皮，查心脏彩超发现冠脉扩张明显扩张。7天前患儿有阵发性咳嗽，有痰咳不出，晨起较剧，咳剧时有呕吐，无皮疹、出血点，无关节疼痛，外院先后以阿莫西林克拉维酸钾、拉氧头孢抗感染。患儿仍有发热，咳嗽未见明显好转，为进一步明确诊治，门诊予以收住入院。* 病程中，患儿精神一般，胃纳欠佳，夜眠一般，小便量偏少，大便稍稀。Error! Picture switch must be first formatting switch.其他：请输入其他Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.3.既往史：Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.传染病史：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.否认Error! Picture switch must be first formatting switch.Error! 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Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.系统回顾：Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.呼吸系统：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.否认Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.气喘、胸闷、结核Error! Picture switch must be first formatting switch.等病史。Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.循环系统：Error! Picture switch must be first formatting switch.否认Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.心慌、晕厥、下肢水肿Error! Picture switch must be first formatting switch.等病史。Error! Picture switch must be first formatting switch.Error! 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Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.个体Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.，健康情况：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.体健Error! Picture switch must be first formatting switch.。母亲有贫血史，未予以重视。母孕期未定期产检。Error! Picture switch must be first formatting switch.父母近亲婚配史：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.否认父母近亲婚配Error! Picture switch must be first formatting switch.。*Error! Picture switch must be first formatting switch.家庭其他成员健康情况：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.均体健，否认遗传性疾病史Error! Picture switch must be first formatting switch.。Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.9.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.体格检查：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.体温：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.肛温Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.37.2Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. 脉搏：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.128Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.次/分Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.呼吸：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.32Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.次/分Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.血压：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formattin