儿科英文病历模板

合集下载

新生儿科英文病历

新生儿科英文病历

以下是一份新生儿科英文病历的范例:Patient: John Doe (Neonate)Date of Birth: DD/MM/YYYYGender: MaleWeight at Birth: 2.5 kgLength at Birth: 48 cmHead Circumference at Birth: 34 cmDelivery Method: Vaginal DeliveryMother's Age at Delivery: 30 yearsMother's Complications during Pregnancy: NoneFather's Age: 35 yearsFamily History: UnremarkablePregnancy History: 1st pregnancy, no previous medical issuesHospitalization History: NoneCurrent Condition: The neonate is born in good condition, with normal respiration and good muscular tone. The baby is active and alert. The cardiovascular system, respiratory system, gastrointestinal system and other systems are normal. The baby does not show any signs of infection or other diseases. The baby's weight, length and head circumference are all within the normal range. The baby's parents are healthy and there is no family history of genetic diseases. The neonate is recommended to continue to be breastfed and receive regular follow-up visits.Diagnosis: Neonate, born in good condition, without any obvious pathological changes. Normal physical development and no signs of disease.Note: It is recommended that the baby continue to be breastfed and receive regular follow-up visits. If there are any changes in the baby's condition, please contact the doctor immediately.。

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

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 throughthe 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。

湘雅二医院儿科英文病例模板

湘雅二医院儿科英文病例模板

CHIEF COMPLAINT
Fever and cough for 10 days with leg pain.
Pharyngalgia and fever for 4 days. [færɪn'gældʒɪə] Cough and dyspnea for 2 days. [dɪs'pni:ə]
PHYSICAL EXAMINATION
Heart: The point of maximal impulse was in left 5th intercostal space on the mid clavicular line. The border of cardiac dullness was normal. Cardiac sounds were strong without splitting and heart rate was 140/min. Cardiac rhythm was regular. No pathological murmur was heard.
T 39.5℃, P 140/min, R 38/min, BP 80/50mmHg Temperature was thirty-nine point five centigrade, Heart rate was one hundred and forty beats per minute, Respiratory rate was thirty-eight times per minute, Blood pressure was eighty over fifty millimeter of mercury
supplementary foods [ˌsʌplɪˈmentri] vaccination [ˌvæksɪ'neɪʃn]

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

儿科腺样体肥大门诊病历范文英文回答:Pediatric Adenoid Hypertrophy Outpatient Medical Record.Patient Information:Name: John Smith.Age: 8 years old.Gender: Male.Date of Visit: January 15, 2022。

Chief Complaint: Difficulty breathing through the nose, snoring at night, recurrent ear infections.Present Illness:I have been experiencing difficulty breathing through my nose for the past few months. It feels like my nose is constantly blocked, and I have to breathe through my mouth most of the time. At night, I snore loudly, which disturbs my sleep. I also have been having recurrent ear infections, which are painful and affect my hearing. These symptoms have been bothering me and affecting my daily activities.Medical History:I have a history of recurrent upper respiratory tract infections, including colds and sore throats. I have also had a few episodes of tonsillitis in the past. My parents mentioned that I had similar symptoms when I was younger, but they improved as I grew older.Physical Examination:On examination, I was found to have nasal congestion with a nasal voice. My tonsils were not enlarged, but my adenoids were visibly enlarged, obstructing the nasal passage. My ears appeared normal externally, butexamination with an otoscope revealed fluid accumulation behind the eardrums.Diagnosis:Based on the history and physical examination findings, I have been diagnosed with pediatric adenoid hypertrophy. This condition refers to the enlargement of the adenoids, which are lymphoid tissues located at the back of the nasal cavity. Adenoid hypertrophy can cause nasal obstruction, snoring, and recurrent ear infections.Treatment Plan:To manage my condition, the following treatment plan has been recommended:1. Nasal Steroid Spray: I will be prescribed a nasal steroid spray to reduce the inflammation and shrink the adenoids, which will help improve nasal breathing.2. Antibiotics: Since I have recurrent ear infections,I will be prescribed a course of antibiotics to treat the current infection and prevent future episodes.3. Adenoidectomy: If my symptoms persist despite medical treatment or if there are complications such as recurrent sinusitis or middle ear infections, my doctor may recommend adenoidectomy. This surgical procedure involves the removal of the adenoids to alleviate the symptoms and prevent further complications.Follow-up:I have been advised to follow up with my doctor in two weeks to assess the response to treatment and discuss further management options if needed.中文回答:儿科腺样体肥大门诊病历范文。

儿科英文病历模板

儿科英文病历模板

Nanjing children’s hospitalMedical Records for AdmissonWard:321 Bed Number:32178 Medical Number: 696235 General informationName:Son of ***Sex: MaleAge: 3 hBirthplace: *** county,Anhui provinceRace:HanAddress:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015Date of record: 3:31pm Oct 16th,2015Parents Name: father *** Mother ***Complainer of history: patient’s fatherReliability: ReliableChief complaint: Shortness of breath and moaning for 3h Present illness:The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.Past historyNo history of any kind of disease.No history of infective diseases. No history of picking front tooth.No history of wiping oral cavity.Personal history1.Natal: second birth born,Gestational age:28 weeks;Multiplets:No;In Vitro fertilization:NoCause of premature birth:unknown;Time of birth:2015-10-16 11:00Mode of delivery:spontaneous delivery,born in local hospital Deliverer:practioner;Apgar scale:1min 7’,5min unknownResuscitation:No;Birth weight:1350gThe characteristics and volume of amniotic fluid remains unknown,as well as whether there was fetal aspiration of amniotic fluid or meconium.we also have no idea if there was Premature rupture of the amniotic fluid.Umbilical cord is normal;Jaundice:unknown2.Nutrition: breast feed has not been initiated.He had no signof defecation or vomit.3.Immunization: B.C.G and hepatitis B vaccine have not beeninoculated after birth;Other vaccination remains unknown. Family historyFather:Name:***;Age:29ys;Vocation:worker;Healthcondition:good;Blood type:ABMother:Name:***;Age:26ys;Vocaton:peasant;Healthcondition:good;Blood type:unknownMother’s history of pregnancies and births:2 pregnancies,no abortion;This pregnancy was normal.Existing siblings: a healthy sister of 2 and half years oldNo history of drug allergy or physical contact with pets;No history of drug abuse or venereal disease.Physical examinationT 34.1℃, P 126/min, R 70/min, BP 54/26mmHg.Weight 1380g. General descriptionHis consciousness is clear;He has Premature appearance,slight cyanosis on the face.He had shortness of breath along with obtuse response and moaning.Skin and mucosaThere is slight cyanosis of the skin.Elasticity is good. No edema.No sign of dehydration.No jaundice.No dermatoma.No bleeding or rash.HeadNo deformities of the Cranium.Anterior fontanelle 2cm*2cm,skin tensity is flat and soft..Hair is black.No hematoma or edema.Seams at the width of 2mm have not been sealed.Eye:Bilateral pupils were round and equal in size about 2mm*2mm. Movement was normal.Direct and indirect pupillary reactions to light were sharp.Conjunctiva was not congestive.No discharges were found around the eyes.Ear:No discharges were found in external auditory canals. No deformity in external auditory canals.Bilateral auricles werewell developed.Nose:No nares flaring. No deformity.Mouth: Oral mucous membrane was intact. No cleft palate. Neck: No resistence during examination. No masses at bilateral sternocleidomastoid muscles.ChestThorax: Symmetric bilaterally.Lungs:Respiratory movement was hyperactive with three concave sign.Breath sound was rough. Moan and goan can be heard as well.Heart:Heart rate 126/min.Heart sounds were strong and no splitting. Cardiac rhythm was regular. No pathological murmurs.Abdomen:Flat and soft. Skin was normal.Gastralintestinal type or peristalses were not seen. No discharges or flare were found in the umbilical area.No umbilical hernnia. Abdominal muscles were soft.Liver was soft.Liver was touched 2cm under the right costal margin but unreachable in subxiphoid regions. Spleen was unreachable under the left costal margin. No masses. Shifting dullness negative. Borborygmus was existent. Spine and Extremities: No deformity. Muscle tensity of all limbs were normal.Extremitis were warm.Capillary filling time was 2s. Neural system: Physiological reflexes were existent without any pathological ones.Anus and External genitalia: External genitalia appeared to be male’s.Anus was existent.No hypospadias.No testes were touched in bilateral scrotum.Specialized InvestigationLaboratory and instrument inspectionBlood sugar(2015-10-16,our hopital):10.8mmol/LClinical Impression:1. ARDS(Acute respiratory dyspnea syndrome) of prematurity2.pneumonia of prematurity3.very low birth weight infantSignature:Diagnosis for admission:1. ARDS(Acute respiratory dyspnea syndrome)of prematurity2.pneumonia of prematurity3.very low birth weight infantSignature:。

儿科英文病历 case report

儿科英文病历 case report

Medical Records for AdmissonMedical Number: General informationName:Age:Sex: Female Race:Han Nationality:China Address: Parents Name:Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s motherReliability: 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 all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptom s didn’t abate. So her parents took her to our hospital, she was adm itted with a diagnosis of “fever of unknown”Since onset, her appetite 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 T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.Personal history1.Natal: First birth born, uneventfully and on full term with birth weight2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsionor bleeding.2.Development: Able to raise head at second month. The first tooth eruptedat 6th. She began to walk at one. Her intelligence was normal.3.Nutrition: She was only feeded with breast milk before she was 6 monthsold. Then the additives were added. She was weaned from the breast at 14th month.4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.Tand smallpox voccination).Physical examinationT 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness.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 discharges 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. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral 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 masses. 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 movement was 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 in 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 murmurs. 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. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system:Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood 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℃, P 120/min, R 30/min, BP 110/90mmHg Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No other positive signs.5.investigation information:Blood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood cytology: A few immature lymphocytes could be seen.Impression: Fever of UnkownAcute Lymphocyte leukaemia?Signature:。

儿童心肌炎病历模板范文

儿童心肌炎病历模板范文

儿童心肌炎病历模板范文Medical Record Template for Childhood Myocarditis.Patient Information.Name:Date of Birth:Medical Record Number:History of Present Illness.Onset of symptoms (date and time):Symptoms: Describe the child's symptoms, including chest pain, shortness of breath, fatigue, fever, and rash.Duration of symptoms:Any recent illnesses or exposures:Family history of myocarditis or heart disease:Physical Examination.Vital signs (temperature, pulse, respiratory rate, blood pressure):General appearance: Describe the child's overall appearance, including any signs of distress, pallor, or cyanosis.Auscultation of the heart: Describe the presence of any murmurs, gallops, or extra heart sounds.Percussion of the heart: Outline the size and location of the heart.Respiratory examination: Describe the child's respiratory effort, breath sounds, and any evidence of wheezing or crackles.Abdominal examination: Assess for any hepatomegaly or splenomegaly.Investigations.Electrocardiogram (ECG): Describe any abnormalities, such as ST-segment elevation, T-wave inversion, or arrhythmias.Chest X-ray: Outline the size and shape of the heart, as well as any signs of pulmonary edema or pleural effusions.Echocardiogram: Evaluate the size and function of the heart, including ejection fraction, wall thickness, and any valvular abnormalities.Cardiac magnetic resonance imaging (MRI): Assess for myocardial inflammation and scarring.Blood tests: Obtain complete blood count, electrolytes,liver function tests, and cardiac enzymes (troponin, creatine kinase-MB).Diagnosis.Childhood myocarditis.Treatment.Supportive care: Provide oxygen, fluid resuscitation, and inotropic support as needed.Anti-inflammatory therapy: Administer corticosteroids (e.g., prednisone) to reduce inflammation.Immunosuppressive therapy: Consider immunosuppressive drugs (e.g., azathioprine, methotrexate) in severe cases.Antiviral therapy: If a viral etiology is suspected, administer antiviral medications (e.g., acyclovir, valacyclovir).Other: Additional therapies may include antibiotics (if infection is present), diuretics (for fluid retention), and antiarrhythmic drugs (for arrhythmias).Follow-Up.Schedule regular follow-up appointments to monitor the child's progress and adjust treatment as needed.Perform serial echocardiograms to assess cardiac function and identify any structural changes.Consider exercise testing to evaluate the child's tolerance for activity.Provide education and counseling to the child and family regarding the condition and its management.中文回答:儿童心肌炎病历模板范本。

早产儿门诊病历书写范文

早产儿门诊病历书写范文

早产儿门诊病历书写范文英文回答:Patient Name: XXX.Age: XXX.Date of Birth: XXX.Gender: XXX.Date of Admission: XXX.Chief Complaint: The patient was born prematurely at 32 weeks of gestation and is presenting with respiratory distress, feeding difficulties, and jaundice.History of Present Illness: The patient was born prematurely and has been experiencing respiratory distress since birth. The patient also has difficulty feeding andhas developed jaundice. The patient was admitted to the neonatal intensive care unit (NICU) for further evaluation and management.Past Medical History: The patient has a history of premature birth and is currently being monitored for potential complications associated with prematurity.Family History: No significant family history reported.Physical Examination: On examination, the patient appears jaundiced. The patient is tachypneic with increased work of breathing. The patient's abdomen is soft and non-tender. The patient's weight is below the 10th percentile for gestational age.Assessment and Plan: The patient is being evaluated for respiratory distress, feeding difficulties, and jaundice. The patient will undergo further diagnostic testing, including blood tests and imaging studies, to determine the underlying cause of the symptoms. The patient will also receive supportive care, including respiratory support andnutritional support, as needed.Disposition: The patient will be admitted to the NICU for further management and monitoring.中文回答:患者姓名,XXX.年龄,XXX.出生日期,XXX.性别,XXX.入院日期,XXX.主诉,患者早产,32周孕龄出生,出生后出现呼吸困难、进食困难和黄疸。

儿科入院病例书写范文

儿科入院病例书写范文

儿科入院病例书写范文英文回答:Pediatric Inpatient Case Presentation.Patient Information.Name: John Doe.Age: 6 years old.Gender: Male.Medical Record Number: 123456789。

Chief Complaint.Fever, cough, and difficulty breathing for the past 3 days.History of Present Illness.John Doe is a 6-year-old male who presents to the emergency department with a 3-day history of fever, cough, and difficulty breathing. The fever has been intermittent, reaching a maximum of 102.2°F. The cough is non-productive and has been getting worse over the past 3 days. Thedifficulty breathing has also been getting worse, and John Doe has been having difficulty sleeping at night.John Doe has no significant past medical history. He is up-to-date on all of his vaccinations. He lives with both parents and has no known allergies.Physical Examination.General: John Doe is a well-developed, well-nourished male in no acute distress.HEENT: John Doe's head is normocephalic and atraumatic. His ears are symmetrical and without discharge. His nose is midline and without discharge. His oropharynx is clearwithout erythema or exudates.Neck: John Doe's neck is supple without lymphadenopathy or thyromegaly.Chest: John Doe's chest is symmetrical with good expansion. Auscultation of the lungs reveals bilateral wheezing.Abdomen: John Doe's abdomen is soft, non-tender, and non-distended. No masses or hepatosplenomegaly are appreciated.Extremities: John Doe's extremities are warm and well-perfused. No clubbing, cyanosis, or edema is noted.Laboratory Studies.Complete blood count: White blood cell count12,000/mm3, hemoglobin 12.5 g/dL, platelets 300,000/mm3。

儿科英文病历模板

儿科英文病历模板

Medical Records for AdmissonMedical Number: 696235 General informationName:Zhang YiAge: thirteenSex: FemaleRace:HanNationality:ChinaAddress: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723Parents Name: father Zhang HeshengMother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001Complainer of history: patient’s motherReliability: 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 all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, 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 appetite 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 T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.Personal history1.Natal: First birth born, uneventfully and on full term with birthweight 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 tootherupted at 6th. She began to walk at one. Her intelligence was normal.3.Nutrition: She was only feeded with breast milk before she was 6months old. Then the additives were added. She was weaned from the breast at 14th month.4.Immunization: Inoculated on schedule after birth (such as B.C.G,D.P.T and smallpox voccination).Physical examinationT 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. 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 discharges 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. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupilswere 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 masses. 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 movement was 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 in 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 murmurs.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. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs. Neural system:Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/L Blood cytology: A few immature lymphocytes could be seen.History summary1.P atient was female, 13 years old2.P haryngalgia and fever for four days.3.N o special past history.4.P hysical examination: T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No other positive signs.5.i nvestigation information:Blood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/L Blood cytology: A few immature lymphocytes could be seen.Impression: Fever of UnkownAcute Lymphocyteleukaemia?Signature: He Lin (95-10033)Welcome To Download !!!欢迎您的下载,资料仅供参考!。

儿童心肌炎病历模板范文

儿童心肌炎病历模板范文

儿童心肌炎病历模板范文英文回答:Medical History Template for Pediatric Myocarditis. Patient Information:Name: [Patient's Name]Age: [Patient's Age]Gender: [Patient's Gender]Date of Admission: [Date of Admission]Date of Birth: [Patient's Date of Birth]Chief Complaint: [Patient's Chief Complaint]Present Illness:The patient presented with symptoms of fatigue, shortness of breath, and chest pain for the past week. The symptoms worsened over time, leading to difficulty in performing daily activities. The patient's parents also noticed a decrease in appetite and occasional fever.Past Medical History:The patient had no significant past medical history. There were no previous hospitalizations or surgeries. The patient's immunization history is up to date.Family History:There is no known family history of cardiac diseases or myocarditis.Physical Examination:On examination, the patient appeared pale and fatigued. Vita l signs were as follows: temperature 38.2°C, heartrate 110 beats per minute, blood pressure 110/70 mmHg, respiratory rate 24 breaths per minute. Heart sounds were normal, with no murmurs or gallops. Lung examination revealed decreased breath sounds in the lower lung fields. No peripheral edema or cyanosis was observed.Laboratory Investigations:Blood tests revealed elevated levels of cardiac biomarkers, including troponin and creatine kinase-MB. Complete blood count showed mild leukocytosis with neutrophil predominance. Other routine blood tests were within normal limits. Electrocardiography (ECG) showed sinus tachycardia and non-specific ST-T wave changes.Imaging:Echocardiography revealed mild left ventricular dysfunction with reduced ejection fraction. There were no structural abnormalities or valvular defects. No pericardial effusion was observed.Diagnosis:Based on the clinical presentation, laboratory investigations, and imaging findings, the patient was diagnosed with acute myocarditis.Treatment:The patient was admitted to the pediatric cardiology unit and started on intravenous antibiotics and antiviral medications. Supportive measures, including bed rest, oxygen therapy, and fluid management, were provided. The patient's symptoms gradually improved over the course of hospitalization.Follow-up:The patient was discharged after 10 days of hospitalization with improved symptoms and stable cardiac function. The parents were advised to monitor the patient's activity level and report any recurrent symptoms or signs of heart failure. A follow-up appointment was scheduled fortwo weeks to assess the patient's progress.中文回答:儿童心肌炎病历模板范文。

儿科英文PBL病例

儿科英文PBL病例

PBL病例
循环及泌尿那节实习
何××,男,2.5岁。

主诉活动后气短2年,加重3个月。

现病史平素易患上呼吸道感染,喂养困难。

生后1个月因“高胆红素血症”在我院就诊时发现心脏杂音,并证实“巨细胞病毒感染”,治疗后好转。

2年前出现声音嘶哑,活动后气短。

既往史肺炎2次。

体格检查体温36.5℃,脉搏90次/分,呼吸24次/分,血压12/8kPa(90/60mmHg),H 82cm, W 10kg,面容无特殊,周身皮肤粘膜及甲床无紫绀,双肺呼吸音清,心前区隆起,心尖搏动弥散,心前区未触及细震颤,左心界第5肋间平左乳头线,右界平胸骨右缘,心音有力心律齐,心率90次/分,胸骨左缘4肋间闻及Ⅲ/Ⅳ级收缩期分流性杂音,肺动脉瓣区第二音亢进,心尖部可闻及舒张期流量性杂音。

肝脏右肋下1厘米,I度硬,脾未触及。

股动脉、足背动脉搏动有力,无杵状指。

问题1 本病的临床特点是什么?
问题2胸骨左缘闻及收缩期杂音,应想到哪些疾病?
问题3进一步应完成哪些辅助检查?其可能结果是什么?
问题4 结合辅助检查,请写出该病例的诊断及诊断依据?
问题5 先心病的病因有哪些?本例患儿的病因最可能是什么?
问题6 上述病人如不经任何治疗,5岁后心杂音反而减轻了,请问这是为什么?对预后有何影响?
问题7 假设该患儿高热持续不退,查体:面色发白,呼吸急促,呼吸48次/分,心率180次/分,肝肋下3cm,脾肋下1cm,请回答可能的并发症及治疗原则?
问题8感染性心内膜炎的诊断依据是什么?
问题9 请为本病制定一个治疗方案。

儿科首次病程记录范文30份左右

儿科首次病程记录范文30份左右

儿科首次病程记录范文30份左右英文回答:Title: Pediatric Initial Course Record.Introduction:The pediatric initial course record provides a comprehensive overview of the patient's medical history, physical examination findings, and initial treatment plan. This record is crucial for accurately documenting the patient's condition and ensuring proper follow-up care. In this article, we will present a sample of 30 pediatric initial course records.Patient Information:Patient Name: [Name]Age: [Age]Gender: [Gender]Date of Admission: [Date]Chief Complaint: [Chief Complaint]Medical History:The patient's medical history includes any relevantpast illnesses, surgeries, allergies, or chronic conditions. It also includes information about the patient's family medical history.Physical Examination Findings:The physical examination findings provide a detailed description of the patient's general appearance, vital signs, and specific examination findings related to thechief complaint. This includes observations such as body temperature, heart rate, respiratory rate, blood pressure, and any abnormal physical findings.Diagnostic Tests:The diagnostic tests section includes any laboratory tests, imaging studies, or other diagnostic procedures that were performed to aid in the diagnosis of the patient's condition.Diagnosis:Based on the patient's medical history, physical examination findings, and diagnostic test results, the diagnosis is determined. This section clearly states the primary diagnosis and any secondary or differential diagnoses considered.Treatment Plan:The treatment plan outlines the initial management approach for the patient. This includes medications prescribed, procedures performed, and any other interventions deemed necessary. It also includesinstructions for follow-up care.Prognosis:The prognosis section provides an assessment of the patient's expected outcome and potential complications. It may also include recommendations for further evaluation or consultations with other specialists if necessary.Follow-up:The follow-up section specifies the recommended follow-up schedule for the patient. This includes future appointments, additional diagnostic tests or procedures, and any necessary referrals.Conclusion:The pediatric initial course record is a vital document that ensures accurate documentation of a patient's medical history, physical examination findings, and initial treatment plan. It serves as a reference for healthcareproviders and assists in providing appropriate and continuous care for pediatric patients.中文回答:标题,儿科首次病程记录。

儿科英文病历模板

儿科英文病历模板

Medical Records for AdmissonMedical Number: 696235 General informationName:Zhang YiAge: thirteenSex: FemaleRace:HanNationality:ChinaAddress: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang HeshengMother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: ReliablChief 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 all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there s he 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 appetite 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 T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.Personal history1.Natal: First birth born, uneventfully and on full term with birth weight2.7 Kg. The stateof 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. Shebegan to walk at one. Her intelligence was normal.3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then theadditives were added. She was weaned from the breast at 14th month.4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpoxvaccination).Physical examinationT 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. Nopigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. 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 discharges 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. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral 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 masses. 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 movement was 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 in 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 murmurs.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. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood 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℃, P 120/min, R 30/min, BP 110/90mmHg Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No other positive signs.5.investigation information:Blood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood cytology: A few immature lymphocytes could be seen.Impression: Fever of UnkownAcute Lymphocyte leukaemia?Signature: He Lin (95-10033)。

儿科呼吸道感染完整病历范文

儿科呼吸道感染完整病历范文

儿科呼吸道感染完整病历范文英文回答:Pediatric Respiratory Infection.Chief Complaint: Respiratory infection.History of Present Illness:The patient is a 4-year-old male who presents to the clinic with a 3-day history of cough, rhinorrhea, and fever. The cough is described as non-productive and dry. Thepatient has also experienced some congestion and nasal discharge. The fever has been low-grade, reaching a maximum of 100.4°F. The patient has not had any vomiting, diarrhea, or shortness of breath.Past Medical History:The patient has no significant past medical history.Medications:The patient is not currently taking any medications.Allergies:The patient has no known drug or food allergies.Social History:The patient lives with his parents and two siblings. He attends daycare three times per week.Family History:The patient's mother has asthma.Physical Examination:General: The patient is in no acute distress. He is well-developed and well-nourished.Head, Eyes, Ears, Nose, and Throat (HEENT): Thepatient's head is normocephalic and atraumatic. His eyes are clear and conjunctiva are pink. His ears are normal in appearance. His nose is congested and there is clear nasal discharge. His oropharynx is clear and without erythema or exudate.Neck: The patient's neck is supple and without adenopathy.Chest: The patient's chest is symmetric with good air movement bilaterally. Auscultation reveals clear breath sounds throughout. There are no wheezes, rales, or rhonchi.Cardiovascular: The patient's heart is regular and no murmurs are appreciated.Abdomen: The patient's abdomen is soft, non-tender, and non-distended. Bowel sounds are normoactive.Genitourinary: The patient's external genitalia arenormal in appearance.Neurological: The patient is alert and oriented to person, place, and time. He has no focal neurological deficits.Assessment:Respiratory infection, most likely viral.Plan:Symptomatic treatment with over-the-counter cough and cold medications.Rest and fluids.Reassurance and follow-up as needed.中文回答:儿科呼吸道感染。

儿童猩红热门诊病历范文

儿童猩红热门诊病历范文

儿童猩红热门诊病历范文英文回答:Scarlet Fever in Children: A Comprehensive Medical Record.Chief Complaint: Scarlet fever.History of Present Illness:The patient is a [age]-year-old child who presents to the clinic with a [duration of symptoms]-day history of a [temperature] fever, [duration of symptoms]-day history of a [description of rash], and [duration of symptoms]-day history of a [description of other symptoms]. The child has been otherwise healthy and has no known allergies.Past Medical History:The child has no significant past medical history.Family History:The child has no family history of scarlet fever or rheumatic fever.Social History:The child lives with both parents and has two siblings. The child attends [grade] grade at [school name].Physical Examination:General: The child is in [condition] condition. They are alert and oriented to person, place, and time.Skin: The child has a diffuse, erythematous rash thatis blanching. The rash is most prominent on the [location of rash]. The child also has [description of other skin findings].Lymph Nodes: The child has palpable, tender lymph nodesin the [location of lymph nodes].Cardiovascular: The child's heart rate is [heart rate] beats per minute and their blood pressure is [blood pressure]. There are no murmurs, gallops, or rubs.Respiratory: The child's respiratory rate is [respiratory rate] breaths per minute. Their lungs are clear to auscultation bilaterally.Gastrointestinal: The child's abdomen is soft and non-distended. There is no tenderness or masses.Genitourinary: The child's genitalia are normal.Neurological: The child's neurological examination is normal.Assessment:Scarlet fever.Differential Diagnosis:Streptococcal pharyngitis.Measles.Rubella.Kawasaki disease.Laboratory Tests:Throat culture.Rapid antigen test for streptococcus. Complete blood count.Erythrocyte sedimentation rate.C-reactive protein.Treatment:Amoxicillin 50 mg/kg/day divided every 12 hours for 10 days.Ibuprofen or acetaminophen for fever and pain.Follow-up:The child should follow up in the clinic in [number] days for a re-check.Instructions:The child should stay home from school until they have completed 24 hours of antibiotic therapy.The child should drink plenty of fluids.The child should avoid contact with other children who are sick.中文回答:儿童猩红热门诊病历。

儿科重症肺炎病例模板范文

儿科重症肺炎病例模板范文

儿科重症肺炎病例模板范文英文回答:Case Study Template for Pediatric Severe Pneumonia. Patient Information.Name:Age:Gender:Medical History:Immunization Status:Chief Complaint.Severe pneumonia.History of Present Illness.Duration of symptoms.Progression of symptoms.Associated symptoms (e.g., fever, cough, shortness of breath)。

Recent travel or exposure to sick contacts.Physical Examination.Vital signs (temperature, heart rate, respiratory rate, blood pressure)。

Oxygen saturation.Respiratory assessment (e.g., wheezing, crackles, decreased breath sounds)。

Cardiovascular assessment (e.g., tachycardia, hypotension)。

Laboratory Investigations.Complete blood count.Blood culture.Chest X-ray.Respiratory viral panel.Other tests as indicated.Management.Oxygen therapy.Intravenous fluids.Antibiotics (e.g., amoxicillin-clavulanate,ceftriaxone)。

儿科英文病例3个

儿科英文病例3个

儿科英文病例Case 1HistoryA 6-year-old boy whom you have never seen before is brought infor evaluation due to difficulty at school. The child's teacherrecommended that he be evaluated for a learning disorder, as hehas failed to grasp material taught in class. The parents state thattheir son has always seemed "slower" than their other two children,but they assumed he was a "late bloomer." Birth history isunremarkable, and the mother reports no problems during herpregnancy. The parents describe the child as happy and healthyotherwise, with no significant past medical history. They mentionthat their prior pediatrician wanted to have the boy tested fordevelopmental delay, but they refused, not wanting to putpressure on him. The parents are unaware of any family history oflearning disorders.ExamT: 98.1°F BP: 102/62 (normal) RR: 14/min. P: 86/min.The child is alert and playful. His height and weight are normal forhis age. His motor function is within normal limits for his age,though he has difficulty following more complex commands, andhis verbal intelligence is somewhat low for his age. Physical examreveals no obvious abnormalities. You recommend formalintelligence testing, to which the parents agree.TestsHemoglobin: 12 g/dL (normal 11-13)White blood cell count: 9100/μL (normal 5000-14,000)Creatinine: 0.5 mg/dL (normal 0.4-0.8)Thyroid-stimulating hormone: 2.2 μU/mL (normal 0.5-3.0)On standard IQ testing, the child is found to have the intellectuallevel of a 4-year-old.ConditionMental retardation, mildThe IQ test reveals an IQ of 66, obtained by the formula: (mental[intellectual] age / chronological age) × 100.PathophysiologyThe large majority (85%) of cases of mental retardation (MR) are mild (defined by an IQ between 55 and 70) and idiopathic. Incidence is more common in males and in those of lower socioeconomic status. In cases where an etiology can be determined, Down syndrome is the most common cause, while fetal alcohol syndrome is the most common preventable cause. Fragile X syndrome, seen in boys, is another common cause of MR. Other causes include cerebral palsy, infections (e.g., TORCH infections), toxin exposure (e.g., lead), cerebral dysgenesis, other chromosomal abnormalities, autism, and metabolic disorders. (Note: TORCH = toxoplasmosis, other [congenital syphilis and viruses], rubella, cytomegalovirus, and herpes simplex virus.)Diagnosis & TreatmentWhenever developmental delay is a concern, the pattern of abnormalities over time is better than any single measurement. Remember, too, that assessment of milestones should take into account prematurity during the first 1-2 years of life (e.g., if the child was born 3 months premature and is 9 months old now, he/she is expected to perform at a 6-month-old level, because 9 months old - 3 months premature = 6-month-old functioning). An organic cause is much more likely to be found in moderate (IQ 35-55) and severe (IQ < 35) MR than in mild MR. MR must also be distinguished from isolated learning disorders (e.g., dyslexia, mathematics learning disorder).Screening is with history and physical exam, with specific verbal and/or motor testing performed if deemed necessary. In moderate and severe MR, chromosomal testing and MRI of the brain are commonly performed; these are not routinely used for mild MR in the absence of other findings (e.g., other physical anomalies, family history).In the setting of poor school performance, don't forget less exotic causes such as hearing/vision difficulties, abuse/neglect, attention-deficit hyperactivity disorder, hypothyroidism, and psychiatric disorders. Screening lead levels may also be appropriate.Avoid using labels with the parents (e.g., "Your child is mentally retarded"). Institute supportive measures once MR is confirmed, such as special education referral and parental counseling.More high-yield factsFragile X syndrome = males (X-linked recessive, though femalecarriers may manifest milder behavioral and intellectualabnormalities) with enlarged testes (macro-orchidism) andfacial dysmorphism (long face; prominent jaw; large, protrudingears).Case 2HistoryA 10-year-old boy presents with excessive weight gain. His fathersays the child is otherwise healthy, but seems to have gained a lotof weight over the last few years; the father wonders if he mighthave some type of medical condition causing the weight gain. Hisson has always been "on the heavy side," but the father assumedhe would grow out of it as he grew taller. The father denies anyother symptoms in the boy and says he has a good appetite. Thechild takes no medications and has no other medical problems.Family history is notable for diabetes, hypertension, and obesity,all of which are present in the child's father.ExamT: 98.6°F BP: 120/80 RR: 14/min. P: 88/min.The boy is alert, responsive, and in no acute distress. His height isat the 58th percentile for age, and his weight is at the 97thpercentile for age. You note no skin abnormalities, and the headand neck examination is unremarkable. His chest is clear toauscultation, and his abdomen is normal except for obesity. Thechild has good muscle tone and strength, with no neurologicdeficits apparent. Sexual development is Tanner stage II.TestsHemoglobin: 12 g/dL (normal 11-14)Sodium: 140 meq/L (normal 135-145)Potassium: 4.0 meq/L (normal 3.5-5.0)Creatinine: 1.0 mg/dL (normal 0.6-1.0)Glucose: 102 mg/dL (normal fasting 60-105)Thyroid-stimulating hormone: 2.5 mU/L (normal 0.4-5.0)ConditionObesityPathophysiologyLess than 5% of cases of obesity are due to an underlying organic etiology (though many parents will want you to name one for them). The remainder of cases are due to both genetic and environmental factors (i.e., multifactorial). Your job on Step 2 is to avoid extensive work-ups in most children, while recognizing a "zebra" cause of obesity if one comes along. Organic causes of obesity include hypothyroidism, Cushing syndrome, insulinoma, central nervous system damage from trauma, tumor or infection, and rare congenital syndromes such as Prader-Willi syndrome.Diagnosis & TreatmentObesity can be defined by several methods. An easy one to use is a weight > 95th percentile for age/sex norms, though this fails to take into account differences in height and body composition. A "weight for height" index also can be used (> 95th percentile for age/sex), as can a subcutaneous fat thickness (skinfolds) measurement (> 85th percentile for age/sex) or body mass index.Following the growth curve or history over time is an important means to detect an organic cause of obesity. When the cause is organic, patients usually have below-normal height and previously had a normal weight with a sudden change in the growth pattern. In addition, other signs are usually present, such as signs of hypothyroidism, Cushing's, mental retardation, and/or neurologic deficits. The large majority of kids havenon-organic causes of obesity, and have a normal orabove-average height and a fairly stable pattern of growth (i.e., obesity) over time.In the absence of a suspicious history or physical findings, anon-organic etiology is almost guaranteed. Some recommend a screening TSH level in all obese children, as kids are less likely to have classic hypothyroidism signs/symptoms. If given the option, screen for hypertension. Diabetes and cholesterol screening may be indicated in children with suggestive personal or family histories (remember, type II diabetes is reaching epidemic proportions in the pediatric age group-a "hot" topic). Inthis case, it would be reasonable to order a glucose tolerance test.Treatment, as in adults, is complex. Starvation diets andmedications should be avoided. A healthy, balanced diet andexercise are the best recommendations.More high-yield factsIn children, obesity increases the risk of hypertension, diabetes,hyperlipidemia, and orthopedic problems, such as slippedcapital femoral epiphyses. The longer children are obese, themore likely they are to be obese as adults.Case 3HistoryYou are called to see an infant in the newborn nursery 1 hour afterdelivery for seizure-like activity. The child was born at term to aprimiparous woman with no prenatal care who needed a cesareansection for failure to progress. He weighed 10 pounds 5 ounces(4680 grams) at birth and had APGAR scores of 7 and 9 at one andfive minutes, respectively. His mother, an obese 29-year-old,reported no difficulties during the pregnancy at the time shepresented for delivery.ExamT: 95.1°F BP: 86/54 (normal) RR: 22/min. P: 174/min. (normal100-160)The macrosomic child is lethargic, and you note that he has aplethoric appearance with round facies. Head and neckexamination is unremarkable, and no scleral icterus is evident. Hischest is clear to auscultation, with mild tachypnea and tachycardianoted. Abdominal exam is unremarkable. No skin or extremityabnormalities are detected. No focal neurologic deficits areappreciated. No physical anomalies are detected.TestsHemoglobin: 22 g/dL (normal 17-22)Sodium: 141 meq/L (normal 135-145)Potassium: 4.1 meq/L (normal 3.5-5)Creatinine: 0.9 mg/dL (normal 0.6-1.1)Glucose: 24 mg/dL (normal 50-110)pH: 7.3 (normal 7.2-7.5)pO2: 72 mmHg (normal 55-80)ConditionHypoglycemic infant of a diabetic mother (IDM)PathophysiologyHypoglycemia is a common event in IDMs, due to fetal islet cell hypertrophy in utero secondary to maternal, and thus fetal, hyperglycemia. After birth, when the maternal source of glucose is removed, the hypertrophied islet cells (beta cells) continue to produce insulin, resulting in neonatal hypoglycemia shortly after birth. Other problems seen more frequently in IDMs than other infants include: macrosomia (> 4000 grams or roughly 9 pounds), cesarean section and birth trauma, respiratory distress syndrome, polycythemia, hypoxia, hyperbilirubinemia, hypocalcemia, persistent pulmonary hypertension, and congenital malformations (e.g., cardiac, central nervous system, musculoskeletal).Tight control of maternal glucose levels during pregnancy reduces the risk of all these complications (including macrosomia). Hemoglobin A1c levels during the first trimester have been positively correlated with the risk of congenital anomalies.Diagnosis & TreatmentMacrosomia is due to maternal diabetes until proven otherwise. IDMs are often plethoric (due to polycythemia) and have round facies. Hypoglycemia causes nonspecific signs in IDMs, usually within a few hours, including abnormal cry, tachypnea, tachycardia, hypothermia, poor feeding, and seizures. The boards may or may not tell you the mother is diabetic.In known IDMs, IV fluids containing glucose are often hung after birth to prevent hypoglycemia, which occurs in about half of IDMs. Respiratory distress syndrome is more common in IDMs, and remember that the presence of phosphatidylglycerol in amniotic fluid is a better marker for fetal lung maturity in IDMs than the lecithin:sphingomyelin ratio. Classic congenital defects in IDMs include ventricular septal defects, hypertrophic cardiomyopathy, small left colon syndrome, and caudal regression syndrome (lower half of body incompletely formed).More high-yield factsOral hypoglycemics are teratogenic and cross the placenta; therefore, they should not be used during pregnancy. Insulin is the diabetes treatment of choice during pregnancy.Screen for congenital defects with ultrasound andalpha-fetoprotein levels prenatally (to detect neural tube and GI defects) in all pregnancies complicated by diabetes.。

  1. 1、下载文档前请自行甄别文档内容的完整性,平台不提供额外的编辑、内容补充、找答案等附加服务。
  2. 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
  3. 3、如文档侵犯您的权益,请联系客服反馈,我们会尽快为您处理(人工客服工作时间:9:00-18:30)。

Medical Records for AdmissonMedical Number: 696235 General informationName:Zhang YiAge: thirteenSex: FemaleRace:HanNationality:ChinaAddress: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang HeshengMother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: ReliablChief 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 all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there s he 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 appetite 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 T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.Personal history1.Natal: First birth born, uneventfully and on full term with birth weight2.7 Kg. The stateof 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. Shebegan to walk at one. Her intelligence was normal.3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then theadditives were added. She was weaned from the breast at 14th month.4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpoxvaccination).Physical examinationT 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. Nopigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. 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 discharges 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. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral 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 masses. 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 movement was 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 in 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 murmurs.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. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood 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℃, P 120/min, R 30/min, BP 110/90mmHg Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No other positive signs.5.investigation information:Blood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/LBlood cytology: A few immature lymphocytes could be seen.Impression: Fever of UnkownAcute Lymphocyte leukaemia?Signature: He Lin (95-10033)。

相关文档
最新文档