儿科腺样体肥大门诊病历范文

儿科腺样体肥大门诊病历范文英文回答：
Pediatric Adenotonsillar Hypertrophy Clinic Visit Note.
Chief Complaint: Recurrent tonsillitis and nasal congestion.
History of Present Illness:
The patient is a 9-year-old male who presents with a 6-month history of recurrent tonsillitis. He has had 4 episodes of sore throat, fever, and swollen lymph nodes in the past 6 months. He has also had persistent nasal congestion and difficulty breathing through his nose. He has been treated with antibiotics for his tonsillitis, but the symptoms have recurred each time.
Past Medical History:
The patient has no significant past medical history. He is up-to-date on his vaccinations.
Family History:
The patient's mother has a history of recurrent tonsillitis.
Social History:
The patient lives at home with his parents and two siblings. He is in the 4th grade and doing well in school. He enjoys playing sports and spending time with his friends.
Review of Systems:
Constitutional: Fatigue, fever, night sweats.
Head: Nasal congestion, difficulty breathing through
the nose, sore throat.
Eyes: No complaints.
Ears: No complaints.
Nose: Nasal congestion, difficulty breathing through the nose.
Throat: Sore throat, swollen tonsils.
Cardiovascular: No complaints.
Respiratory: Difficulty breathing through the nose.
Gastrointestinal: No complaints.
Genitourinary: No complaints.
Musculoskeletal: No complaints.
Neurological: No complaints.
Psychiatric: No complaints.
Physical Examination:
General: The patient is a well-nourished, well-developed 9-year-old male in no acute distress.
Head: Normocephalic. No masses or tenderness.
Eyes: Pupils equal and reactive to light. Extraocular movements intact. No conjunctival injection or discharge.
Ears: Tympanic membranes are intact and mobile. No otorrhea.
Nose: Nasal mucosa is inflamed and swollen. There is a deviated nasal septum to the right.
Throat: Tonsils are enlarged and erythematous. There is a white exudate on the tonsils.
Neck: No lymphadenopathy.
Cardiovascular: Regular rate and rhythm. No murmurs,
gallops, or rubs.
Respiratory: Lungs are clear to auscultation bilaterally. No wheezes or rales.
Gastrointestinal: Abdomen is soft and non-tender. No hepatosplenomegaly.
Genitourinary: No abnormalities noted.
Musculoskeletal: No abnormalities noted.
Neurological: Cranial nerves are intact. Motor and sensory exams are normal.
Assessment:
Adenotonsillar hypertrophy.
Recurrent tonsillitis.
Nasal congestion.
Plan:
Adenotonsillectomy.
Antibiotics for recurrent tonsillitis.
Nasal saline irrigations.
Follow-up:
The patient will follow up in 2 weeks for a post-operative visit.
中文回答：
儿科腺样体肥大手术门诊病历。

主诉，反复扁桃体炎和鼻塞。

现病史：
患者为9岁男性，6个月前出现反复扁桃体炎。

过去6个月内已发作4次咽痛、发热和淋巴结肿大。

他还伴有持续性鼻塞和鼻呼吸困难。

扁桃体炎已用抗生素治疗，但症状每次都复发。

既往病史：
无明显既往病史，疫苗接种情况正常。

家族史：
患者母亲有反复扁桃体炎史。

社会史：
患者与父母和两个兄弟生活在一起。

他上四年级，在学校表现良好。

他喜欢参加体育活动和与朋友相处。

系统回顾：
全身，疲劳、发热、盗汗。

头部，鼻塞、鼻呼吸困难、咽痛。

眼，无异常。

耳，无异常。

鼻，鼻塞、鼻呼吸困难。

咽，咽痛、扁桃体肿大。

心血管，无异常。

呼吸，鼻呼吸困难。

消化道，无异常。

泌尿生殖，无异常。

肌肉骨骼，无异常。

神经系统，无异常。

精神，无异常。

体格检查：
全身，营养状况良好，发育良好的9岁男性，无急性不适。

头部，头部大小正常，无肿块或压痛。

眼，瞳孔大小相等，对光反射灵敏。

眼外运动正常，无结膜充血或分泌物。

耳，鼓膜完整，可活动。

无耳漏。

鼻，鼻粘膜充血水肿，鼻中隔向右侧偏曲。

咽，扁桃体肿大，充血。

扁桃体上有白色渗出物。

颈，无淋巴结肿大。

心血管，心率和心律规则，无杂音、奔马律或摩擦音。

呼吸，双肺听诊无异常，无喘息或啰音。

消化道，腹部柔软，无压痛，无肝脾肿大。

泌尿生殖，无异常。

肌肉骨骼，无异常。

神经系统，颅神经正常，运动和感觉检查正常。

评估：
腺样体肥大。

反复扁桃体炎。

鼻塞。

计划：
腺扁桃体切除术。

反复扁桃体炎抗生素治疗。

鼻腔生理盐水冲洗。

随访：
患者将在2周后随访，进行术后检查。