Admission record

Name: Li Jun, Address:No. XX Road 1220, Shanghai.

Gender: male, narrator of medical history: Lu Yimin, mother, worker.

Age: September Admission Time: 199 1 year 65438+9: 00 on February 6th.

Native place: Shanghai, with medical record at 9: 40.

Ethnic group: Han nationality

Chief complaint: the child was admitted to the hospital for emergency treatment because of coughing for 3 days, aggravated fever and shortness of breath for 3 days. .

Current medical history: The child started from June 5438+February 1 2009. Nose running, cough, paroxysmal dry cough and no phlegm after a cold. After 2 days, the cough is aggravated, and there is phlegm, which is not easy to cough up. On the fourth day, I began to have fever, with the temperature of 38.5 ~ 39.5℃ (anal temperature), accompanied by mild shortness of breath, and cyanosis around my mouth when crying. Children at the beginning of illness take cough syrup by themselves. On February 3, 65438, he went to the local hospital for treatment because of the aggravation of symptoms. After taking erythromycin powder orally for 2 days, his cough still did not relieve. 65438+came to the outpatient department of our hospital on February 5 and was injected with penicillin intramuscular injection. I was admitted to the hospital this morning with a high fever of 39.8℃ and a short cough. After illness, mental food intake became worse, urine was yellow after fever, stool was dry, and there were no symptoms such as asthma, hoarseness, night sweats, hemoptysis, frequent urination, and pus in both ears. No vomiting, diarrhea and convulsions.

Birth history and growth history: one child gives birth at full term, birth weight is 3. 1kg, Apgar score after birth is 10, mixed feeding, mainly milk and milk powder, steamed eggs, biscuits, etc. Starting from 5 months. I have been eating calcium powder intermittently since 6 months, and there is no cod liver oil. Three months will raise your head, four months will laugh at your mother, seven months will help you sit down, and your teeth will sprout. Now you can call your parents and help you stand up.

Past history: Six months later, I had a cold and bronchitis. I usually wake up easily from sleep. I have no history of drug and food allergy. I have been vaccinated with BCG, DTP vaccine and oral poliomyelitis sugar pills. Deny the history of tuberculosis

Family history and genetic disease history: parents are healthy, grandma suffers from coronary heart disease, family members have no bronchial asthma or tuberculosis, and have no medical history.

physical examination

Temperature 39℃(R), pulse 140/ min, respiration 38/ min, weight 8kg. Normal development, good nutrition, automatic posture, conscious, poor spirit, no rash, bleeding point. The superficial lymph nodes of the whole body are not swollen, the skull is slightly square, and the anterior fontanel is 2.0×2.0cm flat. Occipital annular alopecia, symmetrical face and no edema. There is no pus or liquid overflow in both external auditory canals. Mild nasal fan, cyanosis of lips when crying, congestion of throat, soft neck, hypothyroidism and centering of trachea. The chest is barrel-shaped, symmetrical, with slight depression sign, slight Hao Min groove and rib edge eversion, and no obvious beading. The respiratory activity of both lungs is slightly limited, breathing is deep and fast, and the tremor of both lungs is slightly enhanced. Moderate to mild moist rales can be heard in the middle and lower parts of both lungs, especially in the right lung. The precordial area is not elevated, the cardiac boundary is not enlarged, the heart rate 140/min, the rhythm is even, and no murmur can be heard in each valve sound area. P2>A2. The abdomen is flat and soft, with no lump and no tenderness. The lower margin of the liver is 2.5cm below the costal margin of the right clavicle, and the lower margin of the spleen is 0.5cm below the costal margin of the left clavicle. Bowel sounds are not overactive. The external genitalia of anus is normal. There is no deformity in the spine and limbs, and the limbs are still warm, which induces knee reflex and babinski sign is negative.

Auxiliary data: hemogram: hemoglobin 1 10g/L, red blood cells 4.0× 10 12/L, white blood cells 12.0× 109/L, N70%.

Routine examination of feces and urine showed no abnormality.

X-ray chest film shows mottled and fuzzy shadows in the middle and lower parts of both lungs, with the right lung as the focus.

tentative diagnosis

1. bronchopneumonia,

2. Chondromalacia, active stage

Signature of physician: ××

I revised this after reading other people's information. At present, our basic case writing is carried out in this format.