儿科英文病历

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1、GeneralinformationName:ZhangYiAge:thirteenSex:FemaleMedicalRecordsforAdmissonMedicalNumber:696235HeshengMotherYangChiulianDateofadmission:May8th,2001DateofRace:HanNationality:ChinaAddress:,YunchunRoad,Jiefangrecord:11Am,May8th,2001Complainerofhistory:patientsmotherRvenue,Hankou,Hubei.Tel:ParentsName

2、:fatherZhangReliability:ReliableChiefcomplaint:Pharyngalgiaandfeverforfourdays.Presentillness:Thepatientfeltpharyngalgiaandweakaboutfourdaysago.Sheatesomemedicine(notclear),butitdonothing.Thenshefoundulcerinhermouthandfeverallalong,butshefeltnonauseaandnevervomited.SoherparentstookhertoWuhanChildren

3、sHospital,thereshereceivedtreatmentofantibiotics,buthersymptomsdidntabate.Soherparentstookhertoourhospital,shewasadmittedwithadiagnosisof“feverofunknown”Sinceonset,herappetitewasnotgood,andbothherspiritednessandphysicalenergyarebad.Defecationandurinationarenormal.PasthistoryThepatientishealthybefore

4、.Nohistoryof“measles”or“pertussis”etcandnocontacthistorywithorotherinfectivediseases.Noallergyhistoryoffoodbutshewasallergytosulfa.Personalhistory1. Natal:Firstbirthborn,uneventfullyandonfulltermwithbirthweight2.7Kg.Thestateofheratbirthwasgood,nocyanosis,apnea,convulsionorbleeding.Development:Ableto

5、raiseheadatsecondmonth.ThefirsttootheruptedXI*at6th.Shebegantowalkatone.Herintelligencewasnormal.2. Nutrition:Shewasonlyfeededwithbreastmilkbeforeshewas6monthsold.Thentheadditiveswereadded.Shewasweanedfromthebreastat14thmonth.4.Immunization:Inoculatedonscheduleafterbirth(suchasandsmallpoxvoccination

6、).PhysicalexaminationT39.5C,P120/min,R30/min,BP110/90mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerefoundenlargedinherneck,butnoflareandtenderness.HeadCra

7、nium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Non

8、aresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Ora

9、lmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowe

10、dnorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof30/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbr

11、eathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate120/min.Cardiacrhy

12、thmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwastouched1.5cmundertherightcostalmargin.Spleenwas0.5cmundertheleft.Nomasses.Fluidth

13、rillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexanedInvestigationBlood-Rt:Hb59g/LRBCLWBC0.8G/LPLT55G/LBl

14、oodcytology:Afewimmaturelymphocytescouldbeseen.1. HistorysummaryPatientwasfemale,13yearsoldPharyngalgiaandfeverforfourdays.2. Nospecialpasthistory.3. Physicalexamination:T39.5C,P120/min,R30/min,BP110/90mmHgSuperficiallymphnodeswerefoundenlargedinherneck,butnoflareandtenderness.Liverwastouched1.5cmundertherightcostalmargin.Spleenwas0.5cmundertheleft.Nootherpositivesigns.4. investigationinformation:Blood-Rt:Hb59g/LRBCLWBC0.8G/LPLT55G/LBloodcytology:Afewimmaturelymphocytescouldbeseen.Impression:FeverofUnkownAcuteLymphocyteleukaemia