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1、精选优质文档-倾情为你奉上 Medical Records for Admisson Medical Number: General information专心-专注-专业Name: Zhang YiAge: thirteenSex: FemaleRace: HanNationality: ChinaAddress: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: Parents Name: father Zhang Hesheng Mother Yang ChiulianDate of admission: May 8th,
2、2001Date of record: 11Am, May 8th, 2001Complainer of history: patients 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 ul
3、cer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Childrens Hospital, there she received treatment of antibiotics, but her symptoms didnt abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unkn
4、own” Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal. Past history The patient is healthy before. No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy hist
5、ory of food but she was allergy to sulfa.Personal history1. Natal: First birth born, uneventfully and on full term with birth weight 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 tooth erupted at 6
6、th. She began to walk at one. Her intelligence was normal.3. Nutrition: She was only feeded with breast milk before she was 6 months 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
7、 voccination).Physical examination T 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
8、 found enlarged in her neck, but no flare and tenderness.Head Cranium: 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
9、. 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 wer
10、e 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
11、not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Chest Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformitie
12、s. 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 wheeze
13、s. 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 splitti
14、ng. 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
15、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 patholo
16、gical 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
17、.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/L Blood cytology: A few immature lymphocytes could be seen.Impression: Fever of Unkown Acute Lymphocyte leukaemia? Signature: He Lin (95-10033)