《医学英语实用情景教程》（徐青） Unit 4 Pediatrics 儿科

医学英语实用情景教程Unit4Pediatrics儿科知识目标掌握儿科常见疾病的英文术语。掌握询问、描述儿科常见疾病的相关英文表达。掌握儿科英文病历的写法。技能目标能用英语与儿科患者沟通。能读懂儿科相关的英文病历。思政目标不断探索相关知识与技能，从理论中感悟实践，树立“我是祖国的一个小细胞，祖国的发展需要大家共同努力”的观念。项目目标1．学习“知识储备”中的内容，掌握本单元的重点医学术语和常用表达。2．跟读“医患交流”下的英文对话，然后角色扮演各对话场景。3．仔细阅读“病历阅读”下儿科相关的英文病历，总结其中重点句型及词汇。4．完成本单元的“任务检测”。5．根据以上任务的完成情况，给自己评分。任务描述目录123知识储备医患交流病历阅读章节导航01知识储备CommonDiseasesofPediatricsKeyWordsandExpressionsModelSentencesCommonDiseasesofPediatrics新生儿疾病neonatalpneumonia /ˌniːəʊˈneɪtlnjuː'məʊnɪə/ 新生儿肺炎omphalitisofnewborn /ˌɑmfə'laɪtɪsəv'nuːbɔːrn/ 新生儿脐炎neonataljaundice /ˌniːəʊ'neɪtl'dʒɔːndɪs/ 新生儿黄疸convulsionofnewborn /kən'vʌlʃənəv'nuːbɔːrn/ 新生儿惊厥neonatalsepticemia /ˌniːəʊ'neɪtlˌseptə'sɪmɪə/ 新生儿败血症tetanusneonatorum /'tetənəsˌniːɒ'neɪtɔːrʌm/ 新生儿破伤风CommonDiseasesofPediatrics儿科血液系统疾病nutritionalmacrocyticanemia /njʊ'trɪʃənlˌmækrəʊ'sɪtɪkə'nɪmɪə/营养性大细胞性贫血aplasticanemia /eɪ'plæstɪkə'nɪmɪə/再生障碍性贫血infectiousmononucleosis/ɪn'fekʃəsˌmɒnə(ʊ)njuːklɪ'əʊsɪs/传染性单核细胞增多症CommonDiseasesofPediatrics儿童传染性疾病measles /'mɪzəlz/ 麻疹rubella /ruːˈbelə/ 风疹Germanmeasles /'dʒɜːmən'mɪzəlz/ 德国麻疹；风疹varicella /ˌværɪ'selə/ 水痘chickenpox /ˈtʃɪkɪnpɒks/ 水痘roseolainfantum /ˌrəʊzɪ'əʊləɪn'fæntəm/ 婴儿玫瑰疹，奶麻CommonDiseasesofPediatrics儿童传染性疾病exanthemsubitum /ek'sænθəmsjuː'bɪtəm/ 幼儿急疹epidemicparotitis /ˌepɪˈdemɪkˌpærəˈtaɪtɪs/ 流行性腮腺炎mumps /mʌmps/ 腮腺炎bacillarydysentery /'bæsɪlərɪ'dɪs(ə)nt(ə)rɪ/ 细菌性痢疾viralhepatitis /'vaɪrəlˌhepəˈtaɪtɪs/ 病毒性肝炎

CommonDiseasesofPediatrics儿童消化系统疾病thrush /θrʌʃ/ 鹅口疮hand,footandmouthdisease 手足口病stomatitis /ˌstəʊmə'taɪtɪs/ 口腔炎gastroesophagealreflux /ˌɡæstrəʊɪ'sɑfəˌdʒɪəl'rɪˌflʌks/ 胃食管反流infantilediarrhea /'ɪnfəntaɪlˌdaɪə'rɪə/ 小儿腹泻CommonDiseasesofPediatrics其他常见疾病Kawasakidisease /ˌkɑːwə'sɑkɪdɪ'zɪz/ 川崎病childepilepsy /tʃaɪldˈepɪlepsɪ/ 小儿癫痫viralencephalitis /'vaɪrəlenˌsefəˈlaɪtəs/ 病毒性脑炎viralmeningitis /'vaɪrəlˌmenɪnˈdʒaɪtɪs/ 病毒性脑膜炎hyperkineticsyndromeofchildhood/ˌhaɪpəkaɪ'netɪk'sɪndrəməv'tʃaɪldhʊd/ 儿童多动综合征vitaminDdeficientrickets /ˈvɪtəmɪndɪdɪ'fɪʃnt'rɪkɪts/ 维生素D缺乏性佝偻病primarypulmonarytuberculosis /'praɪmərɪˈpʌlmənərɪtjuːˌbɜːkjʊˈləʊsɪs/ 原发型肺结核ascariasis /ˌæskəˈraɪəsɪs/ 蛔虫病KeyWordsandExpressions产科疾病aundice /ˈdʒɔːndɪs/ n. 黄疸recede /rɪˈsɪd/ v. 后退；减弱bilirubin /ˌbɪlɪˈruːbɪn/ n. 胆红素normalvalue /ˈnɔːməlˈvæljʊ/ 正常值physiologic /ˌfɪzɪə'lɒdʒɪk/ adj. 生理的pathological /ˌpæθəˈlɒdʒɪkl/ adj. 病理学的lesion /ˈlɪʒən/ n. （因伤病导致皮肤或器官的）损伤，损害gum /gʌm/ n. 牙龈；齿龈；牙床sorethroat /sɔːθrəʊt/ 喉咙痛intermittent ˌɪntəˈmɪtənt/ adj. 断断续续的；间歇的KeyWordsandExpressions产科疾病cramp /kræmp/ n. 痛性痉挛，抽搐symptom /ˈsɪmptəm/ n. 症状；征兆makeadiagnosis /meɪkəˌdaɪəgˈnəʊsɪs/ 诊断saliva /səˈlaɪvə/ n. 唾液prognosis /prɒgˈnəʊsɪs/ n. （对病情的）预断，预后complication /ˌkɒmplɪˈkeɪʃn/ n. 并发症outpatientclinic /ˈaʊtpeɪʃntˈklɪnɪk/ 门诊部penicillin /ˌpenɪˈsɪlɪn/ n. 青霉素；盘尼西林humidifier /hjuːˈmɪdɪfaɪə(r)/ n. 加湿器moisten /ˈmɔɪsn/ v. 使潮润，使湿润KeyWordsandExpressions产科疾病lastbutnotleast 最后但同样重要的是spoil /spɔɪl/ v. 变质；变坏；腐败formula /ˈfɔːmjələ/ n. 配方奶（母乳的替代品）waterystool /'wɔːt(ə)rɪstuːl/ 水样便mucous ˈmjuːkəs/ n. 黏液；鼻涕parturition /ˌpɑːtjʊˈrɪʃn/ n. 分娩cesarean /sɪˈzeərɪən/ n. 剖宫产tract /trækt/ n. 连通身体组织或器官的道infantileenteritis /ˈɪnfəntaɪlˌentəˈraɪtəs/ 小儿肠炎intestinalflora /ɪnˈtestənəlˈflɔːrə/ 肠道菌群ModelSentences1.Forthebilirubinleveldidn’texceedthenormalvalue,thedoctoradvisedustofeedthebabyfrequently,baskthebabyinthesunshinemoreandpayattentiontothebaby’sskincolor.当时由于黄疸值没有超标，医生建议我们让孩子多吃多拉、多晒太阳，并注意观察孩子皮肤的颜色。3.Don’tworry,thebilirubinlevelisinthenormalrange.不用担心，黄疸值在正常范围内。2.Itseemedthathisskinwasn’tasyellowasbefore.似乎他的皮肤没有之前黄了。ModelSentences4.Ifoundthereweresomerashesontheskinofherhandsandfeet,andshelookedverytired.昨天我发现她手上和脚上出了皮疹，并且精神状态很差。5.It’sakindofcontagiousdiseasethatmainlyhappensinchildren.这是一种传染性疾病，主要发生在小孩身上。7.Doesshehaveanydifficultyinbreathingorcomplaintsofchestpains?她呼吸困难吗？胸痛吗？6.Sheneedsnospecialtreatment.她不需要接受特殊治疗。ModelSentences8.Don’tworry.Mostchildrenmakeacompleterecoveryfrompneumonia.别担心，大多数得肺炎的孩子都能完全康复。9.Ahumidifierwillhelpmoistentheairandmayhelpyourchildbreathebetter.在房间里使用加湿器可以帮助她更好地呼吸。11.Howfrequently?一天几次？10.Ifherconditiongetsworse,bringherbackanytime.如果孩子病情恶化，随时带她来就诊。ModelSentences12.Whatkindofstooldidyounotice,wateryormucous?大便是什么样的？水样便还是黏液样便？13.Issheloosingweight?体重下降了吗？14.Whatabigrelief!我总算放心了！课堂小结这小结我们学习了儿科医学中的常见病、关键词和表达式和模型句子。希望大家能加深对英语词汇的理解并灵活应用。02医患交流Conversation1NeonatalJaundice新生儿黄疸Conversation2Hand,FootandMouthDisease手足口病Conversation3ChildPneumonia儿童肺炎Conversation4Diarrhea腹泻Conversation1NeonatalJaundice新生儿黄疸P:Morning,doctor.D:Morning,sitdown,please.Itseemsthatyourbabystillhasjaundice.P:Heisonemonthold,butjaundicehasn’trecededyet.D:Tellmeabouthiscondition.P:Hisskinturnedyellowobviouslythreedaysafterhisbirth.Forthebilirubinleveldidn’texceedthenormalvalue,doctoradvisedustofeedthebabyfrequently,baskthebabyinthesunshinemoreandpayattentiontothebaby’sskincolor.D:Howdidyourbaby’sskinlooklikeafterleavingthehospital?家长：早上好，大夫。医生：早上好，请坐。似乎你孩子的黄疸还没有退。家长：我的宝宝已经满月了，但是黄疸一直没有退。医生：跟我讲讲你宝宝的情况。家长：他出生3天后皮肤明显变黄，当时由于黄疸值没有超标，医生建议我们让孩子多吃多拉、多晒太阳，并注意观察孩子皮肤的颜色。医生：出院后你宝宝的皮肤看起来怎么样？Conversation1NeonatalJaundice新生儿黄疸P:Itseemedthathisskinwasn’tasyellowasbefore.Butjaundicehasn’trecededcompletely.D:Isee.Takeyourbabytothenurseandcheckthejaundicelevelfirst.P:OK.D:Don’tworry,thebilirubinlevelisinthenormalrange.Ithinkit’sphysiologicjaundice,notapathologicalone.P:Butwhydoesitlastforsuchalongtime?D:Insomespecialcasesittakesabout40to50daystorecedecompletely.P:Thankyouverymuch.家长：似乎他的皮肤没有之前黄了。但黄疸还没有完全退掉。医生：知道了，让护士帮你的宝宝量一下黄疸。家长：好的。医生：不用担心，黄疸值还在正常范围内，应该是生理性黄疸，不是病理性的。家长：但是为什么会持续这么长时间呢？医生：在特别的情况下，需要四五十天才能退完。家长：非常谢谢你。Conversation2Hand,FootandMouthDisease

手足口病D:Goodmorning.Sitdown,please.Whatistroublingyourbaby?P:Goodmorning,doctor.Mybabyisnotverywell.D:Takeiteasy.Tellmemoredetails.P:YesterdayIfoundthereweresomerashesontheskinofherhandsandfeet,andshelookedverytired.D:Letmesee.Therearealsored,blister-likelesionsonthetongue,gumsandinsideofthecheeks.Doesshehaveafeveroraheadacheorapainintheselesionsofskin?P:Yes,shehasasorethroatwhensheiseatingandanintermittentfeverashighas39.2degrees.D:Hasshevomitedorgotacramp?医生：早上好，请坐。你的宝宝怎么了？家长：早上好，大夫。我的宝宝不太舒服。医生：别着急，告诉是我怎么回事。家长：昨天我发现她手上和脚上出了皮疹，并且精神状态很差。医生：我看一下。她的舌头上、牙龈上和面颊内侧也有一些红色的、水泡状的溃疡。她还有其他不适吗？比如发烧、头痛、损伤部位疼痛。家长：她进食时有咽喉痛，间歇性发热，体温最高达到了39.2度。医生：她有没有呕吐或者抽搐？Conversation2Hand,FootandMouthDisease

手足口病P:No.D:Whataboutherappetiteandsleep?P:Shehasapoorappetiteandeatsashalfasnormal.Shedidn’tsleepwelllastnight.D:Didshecontactwithotherkidswhohavesimilarsymptoms?P:Someofherclassmatesinherkindergartenhadsimilarsymptomsandmydaughterplayedgameswiththem.Buttheyhaverecoveredwithouttreatment.D:Isee.Letmetakesomeexamination…OK.IthinkIcanmakeadiagnosisthatshehasgothand,footandmouthdisease.P:Howcanshesufferthisdisease?家长：没有。医生：她的胃口怎么样？睡得好吗？家长：她的胃口变差了，只吃平时的一半。昨天晚上她睡得不好。医生：她最近有接触过出现类似症状的孩子吗？家长：她幼儿园班上的几个同学也有类似的症状，我女儿和他们一起玩过。但是他们在没有接受治疗的情况下痊愈了。医生：我明白了。让我检查一下吧……现在我可以确诊她患的是手足口病。

家长：她怎么会得手足口病呢？Conversation2Hand,FootandMouthDisease

手足口病D:It’sakindofcontagiousdiseasethatmainlyhappensinchildren.Itiscausedbysomevirusandcanbetransmittedfrompersontopersonbysalivaordirectcontact.Generallyspeaking,mostofthepatientshaveagoodprognosis.Butfewofthemmaydevelopsomeseverecomplicationssuchasdamageinthebrain,lungorevenheart.Andtheseareusuallyfatal.P:WhatamIsupposedtodo?D:Accordingtomyexperience,yourbaby’ssituationisnotserious,fornosignsofcomplicationshaveappearedyet.Sheneedsnospecialtreatment.Butyoumustkeepherawayfromotherkidsuntiltherashesdisappear.Ithinkitwilltake3—5days.P:Thankyousomuch,doctor.D:That’sallright.Remembertoletherhaveagoodrest.医生：这是一种传染性疾病，主要发生在小孩身上。它是由一些病毒引起的，主要通过唾液及直接接触传染。一般来说，大部分患者预后良好。少数会出现脑部、肺部甚至心脏并发症，这些并发症往往是致命的。家长：那我该怎么做呢？医生：根据我的经验判断，你孩子的情况并不严重，不需要特殊治疗，因为没有产生并发症的迹象。但在她身上的皮疹消失前，你必须让她和别的孩子隔离开，大概需要3～5天的时间。家长：非常感谢您，大夫。医生：不客气。记住要让她好好休息。Conversation3ChildPneumonia儿童肺炎P:Mychildhashadafeverandcoughedforfourdays.Andtheconditionwasgettingworseyesterday.D:Doesshehaveanydifficultyinbreathingorcomplaintsofchestpains?P:She’sweakandcan’tbreatheeasily.D:I’llexamineherlungs…Mostlikely,it’spneumonia.BringhertotakeachestX-ray.Andcomebacktomewiththeresult.(aftertheexamination)D:Yes,shehaspneumonia.P:Isitserious?Isthereanydangerofthiskindofdisease?D:Don’tworry.Mostchildrenmakeacompleterecoveryfrompneumonia.AndIthinksheshouldbeadmittedtohospitalfortreatment.家长：我家孩子发烧咳嗽四天了。昨天起情况加重了。医生：她呼吸困难吗？胸痛吗？家长：她软弱无力，呼吸困难。医生：让我检查一下她的肺部。很可能是肺炎。带她去做一个胸部X光检查，带着结果回来找我。（检查后）医生：不错，她得了肺炎。家长：病情重吗？有危险吗？医生：别担心，大多数得肺炎的孩子都能完全康复。我建议她住院治疗。Conversation3ChildPneumonia儿童肺炎P:Oh,Ihaveanotherchildathometotakecareof.Isitpossibletohavehertreatedintheoutpatientclinic?D:Yes,Iwouldliketogiveherpenicillininjectionstwiceadayfortwodays.Issheallergictopenicillin?P:No.HowshouldItakecareofherathome?D:First,sheneedstogetplentyofrestanddrinklotsoffluidstorecoverfrompneumonia.Second,ahumidifierwillhelpmoistentheairandmayhelpyourchildbreathebetter.Lastbutnotleast,itiswisetokeepyourchildwithpneumoniaawayfromotherchildren,toavoidthespreadofdisease.家长：家里还有别的孩子需要我照顾，这孩子就在门诊治疗行吗？医生：可以。我要给她注射青霉素一天两次，共两天。她对青霉素过敏吗？家长：不过敏。我在家应该怎样照顾她呢？医生：第一，她需要多休息、多喝水。第二，在房间里使用加湿器可以帮助她更好地呼吸。最后但同样重要的是，让患肺炎的孩子远离其他孩子，以控制疾病的传播。

Conversation3ChildPneumonia儿童肺炎P:OK,anythingelse?D:Don’tforgettocomebacktotheclinicforherinjectionstwiceaday.Ifherconditiongetsworse,bringherbackanytime.P:Allright,thankyou,doctor.Iwillfollowyouradvice.家长：还有其他需要注意的吗？医生：别忘了每天到门诊来注射两次药。如果孩子病情恶化，随时带她来就诊。家长：好的，谢谢您，大夫。我一定会听从您的医嘱。Conversation4Diarrhea腹泻D:Goodmorning!Haveaseat,please.What’swrongwithyourdaughter?P:Mydaughterissufferingfromdiarrheaaftereatingspoiledformula.D:Whendiditstart?Howfrequently?P:Itstartedtwodaysago.Shegoestothetoilet8to10timesaday.D:Whatkindofstooldidyounotice,wateryormucous?P:Yellowish-greenwaterystools.D:Isshelosingweight?P:No,theweightdidnotchangesignificantly.D:Hasshetakenanymedicine?医生：早上好！请坐。你女儿哪里不舒服？家长：我家女儿食用了变质奶粉后开始腹泻。医生：是从什么时候开始的？一天拉几次？家长：两天前开始的，一天8～10次。医生：大便是什么样的？水样便还是黏液样便？家长：黄绿色稀水便。医生：体重下降了吗？家长：没有，体重没有明显变化。医生：吃药了吗？Conversation4Diarrhea腹泻P:Notyet.D:Doesshehaveanyotherproblems?P:Halfadaybefore,shegotafever.Thehighestbodytemperatureis38.5℃.D:Whataboutherparturition,naturalorcesarean?P:Cesarean.D:Hasshesufferedfromotherdiseasesbefore?P:Sheishealthyandhasneverbeenill.D:Forthree-month-oldbaby’sgastrointestinaltractisnotfullydeveloped,shewasprobablysufferingfrominfantileenteritiscausedbythespoiledformula.Sheneededtobehospitalizedforafewdaystoregulateherintestinalflora.家长：还没有。医生：还有其他症状吗？家长：半天前，她开始发热，最高体温达38.5℃。医生：她的分娩过程呢？顺产还是剖宫产？家长：剖宫产。医生：她以前得过别的病吗？家长：她平常很健康，没得过病。医生：3个月婴儿的胃肠道发育尚未成熟，她大概是由于食用变质奶粉而引起了小儿肠炎。她需住院几天调节肠道群菌。

Conversation4Diarrhea腹泻P:Isthediseaseserious,doctor?D:Notsoserious.Withpropertreatment,shewillgetbettergradually.P:Whatabigrelief!Thankyouverymuch.家长：我女儿的病严重吗，医生？医生：不是特别严重，经过适当治疗她会逐渐恢复的。家长：这样我总算放心了！谢谢您了，医生。课堂小结这小结我们学习了如何用英语进行医患交流。希望大家课下多加复习，加深对英语的灵活应用。03病历阅读OutpatientMedicalRecords—NeonatalJaundiceAdmissionMedicalRecords—PneumoniaPhysicalExamination—InfantilePneumoniaChiefComplaint:Thepatienthadxanthochromiafor20daysandseveralhours.HistoryofPresentIllness:Thepatienthadjaundicethreedaysafterbirth.Thejaundicereachedpeakvalueonthesixthdayandwasreducedafterwards,butthereductionwasslowandthejaundicedidnotcompletelydisappearuntilnow.PastMedicalHistory:Thepatient’smotherwashealthyduringpregnancy,withoutcontacthistoryofacuteandchronicinfectiousdiseasessuchastuberculosisetc.PersonalHistory:Thepatient’smotherstartedexclusivebreastfeedingwithin30minafterdeliveryaccordingtothepatient’sdemand.Thepatienthadthefirstdefecation1hourafterbirth,andhadbeeninoculatedwithBCGvaccineandhepatitisBvaccine.Thepatientwasthesecondchildandwasdeliveredthroughnaturallaborin39+3-weekpregnancy.OutpatientMedicalRecords—NeonatalJaundicePhysicalExamination:T37.8℃;P130bpm;R40times/min;Wt4.1kg;height52cm;headcircumference37cm.Thepatientwasconsciouswithsensitivereactionforflippingofpelma.Thepatienthadnormalappearanceofthenewborn,withflushingcomplexion,stablerespirationandloudcrying.AuxiliaryExamination:Bilirubin23mg/dLPrimaryDiagnosis:PhysiologicjaundiceTreatment:1.OrallytakeYinzhihuangoralliquidandmedilac-vita;takereexaminationafteronecourse.2.Sticktobreastfeeding;feedsomewaterproperly.Doctor’sSignature:Liu××OutpatientMedicalRecords—NeonatalJaundiceOutpatientMedicalRecords—NeonatalJaundice门诊病历—新生儿黄疸主诉：皮肤黄染20余天。现病史：出生后第三日出现黄疸，第六日达到峰值，后黄疸有所下降，但下降缓慢，至今未完全退却。既往史：母孕期体健，无结核等急、慢性传染病接触史。个人史：出生后30分钟内开始喂奶。纯母乳喂养。按需喂养。生后1小时第一次排便。卡介苗、乙肝疫苗已接种。患儿系第二胎，孕39+3周顺产。体格检查：T37.8℃，P130次/分，R40次/分，Wt4.1kg，身长52cm，头围37cm。神志清，弹足底反应灵敏，正常新生儿外貌，面色红润，呼吸平稳，哭声响亮。辅助检查：胆红素23mg/dL。初步诊断：生理性黄疸处理：1．口服茵栀黄口服液和妈咪爱，一疗程后复查。2．坚持母乳喂养，可适当喂水。医师签名：刘××Name:Zhu×× Gender:MaleAge:3yearsold Race:HanOccupation:Other MaritalStatus:UnmarriedNationality:China NativePlace:××PresentAddress:×××× RepresentorofMedicalHistory:Patient’smotherDateofAdmission:2ndJul.,2019 Dateofrecord:10:36,2ndJul.,2019ChiefComplaint:Thepatienthadcoughsandexpectorationaccompaniedwithtightnessinbreathingfor1weekandseveraldays.HistoryofPresentIllness:(Narratedbythepatient’smother)Thepatienthadcoughsandexpectorationaftergettingacold1weekago.AdmissionMedicalRecords—PneumoniaThecoughswerecontinuous,itwasdifficulttobeexpectoratesputum,accompaniedwithtightnessinbreathing,sneezing,nasalobstructionandrunningnose,withoutfever,vomiting,convulsion,coma,afternoonhecticfever,nightsweat,cyanosis,stomachacheanddiarrheaetc.Thepatientwasevertreatedinalocalprivateclinic,withunknownspecificmedication,andtheeffectwasnotgood.Thecoughs,expectorationandtightnessinbreathingwereevidentlyaggravated.Forfurthertreatment,theyvisitedclinicofourhospital,andthepatientwasadmittedintoourdepartmentas“neonatalpneumonia”.Sincetheonset,thepatient’sspirit,appetiteandsleepwerepoor,withbasicallynormalstoolandurination.PastMedicalHistory:Thepatientwashealthypreviously,anddeniedmedicalhistoryofacuteandchronicinfectiousdiseasessuchaschickenpox,tuberculosisandmeaslesetc.AdmissionMedicalRecords—PneumoniaThehistoriesofseveretrauma,operation,transfusionandfoodanddrugallergyweredenied.Prophylacticvaccinationwasperformedasscheduled.Complementaryfoodwasprovidedatpropertime.Thepatientwasabletoraisetheheadin2months,turnoverin4months,sitindependentlyin7months,crawlin8monthsandwalkinoneyear.Thegrowthanddevelopmentwerenormal.FamilyHistory:Thepatient’sparentswerehealthywithoutconsanguineousmarriage.Therewasnosimilardiseaseinthefamily,andfamilygeneticdiseasewasdenied.Doctor’sSignature:Zhu××AdmissionMedicalRecords—PneumoniaAdmissionMedicalRecords—Pneumonia入院病历（病史采集）—肺炎姓名：朱×× 性别：男年龄：3岁 民族：汉职业：其他 婚姻状况：未婚国籍：中国 籍贯：××现住址：×××× 病史陈述者：患者母亲入院日期：2019-07-02 病历记录时间：2019-07-02，10:36主诉：咳嗽、咳痰伴气紧1+周。AdmissionMedicalRecords—Pneumonia入院病历（病史采集）—肺炎现病史：（患儿母亲代述）患儿于1周前受凉后开始出现咳嗽、咳痰，呈连续性咳嗽，有痰难咳出，伴气紧、打喷嚏、鼻塞、流涕。无发热、呕吐、抽搐、昏迷，无午后潮热、盗汗、发绀，亦无腹痛、腹泻等症状。曾在当地私人诊所治疗，具体用药不详，效果不理想。且咳嗽、咳痰、气紧明显加重，为求进一步治疗而于今日来我院门诊就诊，拟诊“新生儿肺炎”收入我科住院治疗。病后患儿精神、食欲、睡眠差，大、小便基本正常。既往史：平素体健，否认水痘、结核、麻疹等急、慢性传染病史，否认重大外伤及手术史，无输血史，否认食物及药物过敏史，按计划预防接种。适时添加各种辅食，二个月会抬头，四个月会翻身，七个月能独坐，八个月会爬，一岁会走路，生长发育如同龄儿。家族史：父母体健，非近亲婚配。家庭中无类似疾病，否认家族遗传性疾病。医生签名：朱××Temperature:37.6℃ Pulse:142bpmRespiratoryRate:68bpm BloodPressure:74/48mmHg Weight:8,100gThepatient’sgrowthwasnormal,withmoderatenutrition.Thepatientwasconsciouswithapoorspirit,acutecomplexion,appearanceofwheezeandactiveposition,andwasnotcooperativeforexamination.Noyellowstaining,hemorrhagicspotandrashwerefoundonskinandmucosaalloverthebody.Theskinwaselasticwithoutedema.Noenlargementofsystemicsuperficiallymphnodeswasfound.Nodeformationofskullwasfound.Thebregmawasclosed,withoutpressurealopecia.Noedemaofeyelids,hyperemiaandedemaofconjunctiva,andyellowstainingofsclerawasfound.Thecorneawastransparent.Eyemovementswerefree.Bilateralpupilswereequalandround,withadiameterof3mm,andwerereactivetolight.……详见课本第82页PhysicalExamination—InfantilePneumoniaPhysicalExamination—Infanti