病史汇报BO英文__培训课件.ppt

Case Abstract Hunan Childrens Hospital Department I of Respiratory Wubichen Details of the patient 1 Chief Complaint 2 5 Laboratory Results 4 HPI, Past history， Family history Physical Examination Treatments 3 6 Details of the patient Age:10 months Sex:male Chief Complaint Recurrent cough and wheezing for 2 months Present illness The child developed a recurrent paroxysmal cough accompanied by wheezing in the recent 2 months, particularly at night, which worsened after exercise, with scanty sputum and no tachypnea, no cyanosis. At first，no fever. Present illness He went to Xiangya Hospital, with treatment more than 10 days, the condition was the same. Then sometimes he had fever. So he transferred to our department. Present illness The CT showed lung consolidation. After treatment with antibiotics( imipenem, fusidinic) and antiasthmatic ( methylprednisolone, aminophylline, budesonide, salbutamol, ipratropium bromide), cough and fever improved. Present illness But he still had mild wheezing. Then he went home, and still had treatment with inhalation of budesonide, salbutamol, ipratropium. Present illness Five days ago，his cough and wheezing increased again. After treatment with “Cefminox and azithromycin”for 2 days, her symptoms were not improved. For the further diagnosis and treatment, he went to our department again. Past History Have a history of severe pueumonia by adenovirus infection when he was 6 month. The patient usually has eczema. History G1P1, Being breast feeded for 3 months after birth, and milk feeded afterward No bad special addiction No drug allergy Family History Both of her parents have no asthma history. Physical Examination T37.0℃ ;P:116bpm; RR :30bpm Weight:10Kg Clear in mentality Middle developed Good skin elasticity,no jaundice Superficial lymph nodes are not palpabled Physical Examination Bilateral pupils were round and equal in size. Direct or in