儿科英文病历

1、Medical Records for AdmissonMedical Number: 696235General informationName: Zhang YiAge: thirteenSex: FemaleRace: HanHeshengMother Yang ChiulianDate of admission: May 8th, 2001 Date of record: 11Am, May 8th,Nationality: ChinaAddress: , Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel:2001Complainer o

2、f history: patient s motherParents Name: father Zhang Reliability: ReliableChief 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 ulcer in her mouth and fever

3、 all along, but she felt no nausea and never vomited. So her parents took her to Wuhan ChildrensHospital, 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 unknown ”Since onset, her appe

4、tite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.Past historyThe patient is healthy before.No history of “measles” or “pertussis ” etc and no contact history with or other infective diseases. No allergy history of food but she was allergy

5、to sulfa.Personal history1. Natal: First birth born, uneventfully and on full term withbirth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding.2. Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her

6、 intelligence was normal.3. Nutrition:She was only feeded with breast milk before she was6 months old. Then the additives were added. She was weanedfrom the breast at 14 th month.4.I mmunization: Inoculated on schedule after birth (such asand smallpox voccination).Physical examinationT 39.5 C , P 12

7、0/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. Nocyanosis. Nopigmentation. Noskin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tend

8、erness. HeadCranium: Hair was black and well distributed. No deformities.No scars. No masses. No tenderness.Ear: Bilateral auricles 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 disch

9、arges were found in vetibulum nasi.Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.Eye:Bilateral eyelids were not swelling. No ptosis. Noentropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilate

10、ral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane 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 mas

11、ses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: 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 movementwa

12、s bilaterally 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 i

13、n precordial 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 mur

14、murs.Abdomen: 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. N

15、o masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movementsof all limbs. Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedInve

16、stigationBlood-Rt: Hb 59g/L RBC L WBC 0.8G/L PLT 55G/L Blood cytology: A few immature lymphocytes could be seen.History summary1. Patient was female, 13 years old2. Pharyngalgia and fever for four days.3. No special past history.4. Physical examination:T 39.5 C , P 120/min, R 30/min, BP110/90mmHg Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Liver was touched 1.5cm under the righ