大叶性肺炎(国外英文资料).docVIP

大叶性肺炎 Gushi county peoples hospital Codon: the pediatric ward: no. 4: no. 13 hospital number:The first hospitalization history: no Name: Chen mingkun Gender: male Age: 8 years old Nationality: gushi county, henan province Occupation: student Marriage: unmarried Ethnic composition: the han Admission date: 2012-09-8 Present address: west of gushi county Zip code: 465200 Date of record: 2012-09-8 Contact: liu junfeng and patient relationship: uncle Medical history: I and my family Contact address: gushi county west gate:Reliability: reliability Chief complaint: cough, fever 4 days. Hpi: patients due to 4 days no obvious cause cough associated with fever, T: 39.0 ℃, dry cough, o. No fever, abdominal pain, diarrhea, chest irritation. In the local health hospital, the treatment (specific use of the drug) was not good and the symptoms were not improved. The cough, fever and fever gradually increased, and came to our hospital today for examination. The outpatient clinic was diagnosed with large leaf pneumonia. The patient has a mental illness, poor mental health, poor diet, sleep, and normal urine. History of the past: the past, the history of non-surgical trauma, denied the history of hepatitis tuberculosis infection, the denial of drug and other allergy history, the prevention of inoculation with the society. Personal history: children G1P1, full term, natural birth, birth asphyxia, the whole body have no blue, crying loudly, score is unknown, born after breastfeeding, 3 months when they looked up, 8 months when they call mom and dad. Family history: parents are healthy; Non-inbreeding, which denies the history of specific and familial hereditary diseases. Physical check T: 39.7 ℃ P: 110 times/min R: 28 times/min Wt: 23 kg Development is normal, the spirit is clear, the spirit is poor, whole body skin mucous membrane green purple not see the yellow dye, the blood point and the spider, the superficial lymph nodes do not touch the swelling. There is