儿科英文病历

MedicalRecordsforAdmissonMedicalNumber:696235GeneralinformationName:ZhangYiAge:thirteenSex:FemaleRace:HanNationality:ChinaAddress:NO.23,YunchunRoad,JiefangRvenue,Hankou,Hubei.Tel:[phone]ParentsName:fatherZhangHeshengMotherYangChiulianDateofadmission:May8th,2001Dateofrecord:11Am,May8th,2001Complainerofhistory:patient’smotherReliability:ReliableChiefcomplaint:Pharyngalgiaandfeverforfourdays.Presentillness:Thepatientfeltpharyngalgiaandweakaboutfourdaysago.Sheatesomemedicine(notclear),butitdonothing.Thenshefoundulcerinhermouthandfeverallalong,butshefeltnonauseaandnevervomited.SoherparentstookhertoWuhanChildren’sHospital,thereshereceivedtreatmentofantibiotics,buthersymptomsdidn’tabate.Soherparentstookhertoourhospital,shewasadmittedwithadiagnosisof“feverofunknown”Sinceonset,herappetitewasnotgood,andbothherspiritednessandphysicalenergyarebad.Defecationandurinationarenormal.PasthistoryThepatientishealthybefore.Nohistoryof“measles”or“pertussis”etcandnocontacthistorywithT.Borotherinfectivediseases.Noallergyhistoryoffoodbutshewasallergytosulfa.Personalhistory1.Natal:Firstbirthborn,uneventfullyandonfulltermwithbirthweight2.7Kg.Thestateofheratbirthwasgood,nocyanosis,apnea,convulsionorbleeding.2.Development:Abletoraiseheadatsecondmonth.Thefirsttootheruptedat6th.Shebegantowalkatone.Herintelligencewasnormal.3.Nutrition:Shewasonlyfeededwithbreastmilkbeforeshewas6monthsold.Thentheadditiveswereadded.Shewasweanedfromthebreastat14thmonth.4.Immunization:Inoculatedonscheduleafterbirth(suchasB.C.G,D.P.Tandsmallpoxvoccination).PhysicalexaminationT39.5℃,P120/min,R30/min,BP110/90mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerefoundenlargedinherneck,butnoflareandtenderness.HeadCranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.Eye:Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.Mouth:Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.Neck:Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.ChestChestwall:Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.Thorax:Symmetricbilaterally.Nodeformities.Breast:Symmetricbilaterally.Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof30/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.Heart:Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate120/min.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Therewasnottendernessandreboundtendernessonabdomenorrenalregion.Liverwastouched1.5cmundertherightcostalmargin.Spleenwas0.5cmundertheleft.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmus5/min.Novascularmurmurs.Extremities:Noarticularswelling.Freemovementsofalllimbs.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.Genitourinarysystem:Notexamed.Rectum:notexanedInvestigationBlood-Rt:Hb59g/LRBC1.90T/LWBC0.8G/LPLT55G/LBloodcytology:Afewimmaturelymphocytescouldbeseen.Historysummary1.Patientwasfemale,13yearsold2.Pharyngalgiaandfeverforfourdays.3.Nospecialpasthistory.4.Physicalexamination:T39.5℃,P120/min,R30/min,BP110/90mmHgSuperficiallymphnodeswerefoundenlargedinherneck,butnoflareandtenderness.Liverwastouched1.5cmundertherightcostalmargin.Spleenwas0.5cmundertheleft.Nootherpositivesigns.5.investigationinformation:Blood-Rt:Hb59g/LRBC1.90T/LWBC0.8G/LPLT55G/LBloodcytology:Afewimmaturelymphocytescouldbeseen.Impression:FeverofUnkownAcuteLymphocyteleukaemia?