病史汇报BO英文

Case Abstract,Hunan Childrens Hospital Department I of Respiratory,Wubichen,Details of the patient,1,Chief Complaint,2,5,Laboratory Results,4,HPI, Past history，Family history,Physical Examination,Treatments,3,6,Details of the patient,Age:10 monthsSex:male,Chief Complaint,Recurrent cough and wheezing for 2 months,Present illness,The child developed a recurrent paroxysmal cough accompanied by wheezing in the recent 2 months, particularly at night, which worsened after exercise, with scanty sputum and no tachypnea, no cyanosis. At first，no fever.,Present illness,He went to Xiangya Hospital, with treatment more than 10 days, the condition was the same. Then sometimes he had fever. So he transferred to our department.,Present illness,The CT showed lung consolidation. After treatment with antibiotics( imipenem, fusidinic) and antiasthmatic ( methylprednisolone, aminophylline, budesonide, salbutamol, ipratropium bromide), cough and fever improved.,Present illness,But he still had mild wheezing. Then he went home, and still had treatment with inhalation of budesonide, salbutamol, ipratropium.,Present illness,Five days ago，his cough and wheezing increased again. After treatment with “Cefminox and azithromycin”for 2 days, her symptoms were not improved. For the further diagnosis and treatment, he went to our department again.,Past History,Have a history of severe pueumonia by adenovirus infection when he was 6 month.The patient usually has eczema.,History,G1P1, Being breast feeded for 3 months after birth, and milk feeded afterward No bad special addictionNo drug allergy,Family History,Both of her parents have no asthma history.,Physical Examination,T37.0 ;P:116bpm; RR :30bpm Weight:10KgClear in mentalityMiddle developedGood skin elasticity,no jaundice Superficial lymph nodes are not palpabled,Physical Examination,Bilateral pupils were round and equal in size. Direct or indirect light pupillary reflex was existent No cyanosis,Physical Examination,Trachea is in the midline . Smooth breathing.No three concave signThe shape of thoracic is normal.,Physical Examination,Lung auscultation: diffuse wheeze which is mainly in the expiratory phase, mild wet rales in inspiratory phase.,Physical Examination,Heart percussion: Normal cardiac sectorThe cardiac auscultation: Rhythm neat ,no heart murmur heard,Physical Examination,Abdomen is flat and softLiver can not be palpabled below costal marginSpleen can not be feltBowel sound is active,Physical Examination,No percussion pain in bilateral renal regionExtremities and the activities of it are normal, no clubbing nailsNeurological exam: Negative,Routine Blood Test,WBC 12.33*109/LN% 47.2%L% 44.9%Hb121g/LPLT 318*109/LRoutine Urine Test and Routine Stool Test both are in normal limits,Laboratory Results,ESR17mm/hElectrolytes、liver function and myocardial enzyme:normal.CT: lung consolidation，mosaic sign,HRCT:westermark sign,Laboratory Results,Allergen tests: negtiveImmune test: Ig G：7.60g/L， Ig A：0.42g/L， Ig M：7.60g/L，C3:0.68g/L, C4:0.14g/L, Ig E：164.1IU/mLPulmonary function testing: middle airflow obstruction,Diagnosis,bronchiolitis obliterans,BO,diagnosis,Recurrent cough and wheezing for 2 months a history of severe pueumonia by adenovirus infection when he was 6 month ，