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1、MedicalRecordsforAdmissonMedicalNumber:696235GeneralinformationName:ZhangYiAge:thirteenSex:FemaleRace:HanNationality:ChinaAddress:NO.23,YunchunRoad,JiefangRvenue,Hankou,Hubei.Tel:85763723ParentsName:fatherZhangHeshengMotherYangChiulianDateofadmission:May8th,
2、2001Dateofrecord:11Am,May8th,2001Complainerofhistory:patient’smotherReliability:ReliableChiefcomplaint:Pharyngalgiaandfeverforfourdays.Presentillness:Thepatientfeltpharyngalgiaandweakaboutfourdaysago.Sheatesomemedicine(notclear),butitdonothing.Thenshefoundul
3、cerinhermouthandfeverallalong,butshefeltnonauseaandnevervomited.SoherparentstookhertoWuhanChildren’sHospital,thereshereceivedtreatmentofantibiotics,buthersymptomsdidn’tabate.Soherparentstookhertoourhospital,shewasadmittedwithadiagnosisof“feverofunknown”Since
4、onset,herappetitewasnotgood,andbothherspiritednessandphysicalenergyarebad.Defecationandurinationarenormal.PasthistoryThepatientishealthybefore.Nohistoryof“measles”or“pertussis”etcandnocontacthistorywithT.Borotherinfectivediseases.Noallergyhistoryoffoodbutshe
5、wasallergytosulfa.Personalhistory1.Natal:Firstbirthborn,uneventfullyandonfulltermwithbirthweight2.7Kg.Thestateofheratbirthwasgood,nocyanosis,apnea,convulsionorbleeding.2.Development:Abletoraiseheadatsecondmonth.Thefirsttootheruptedat6th.Shebegantowalkatone.H
6、erintelligencewasnormal.3.Nutrition:Shewasonlyfeededwithbreastmilkbeforeshewas6monthsold.Thentheadditiveswereadded.Shewasweanedfromthebreastat14thmonth.4.Immunization:Inoculatedonscheduleafterbirth(suchasB.C.G,D.P.Tandsmallpoxvoccination).Physicalexamination
7、T39.5℃,P120/min,R30/min,BP110/90mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerefoundenlargedinherneck,butnoflare
8、andtenderness.HeadCranium:Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.Ear:Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals
