兒科標準病歷範本
一.【UTI】
Chief complaint:
Intermittent fever up to 40'C for 4 days.
Present Illness:
According to the statements of her mother, this 2-year-old girl suffered from intermittent high fever up to 40'C with chills for 4 days,along with mild cough butno rhinorrhea. Her mother also noted that she had poor appetite, vomiting and constipation with small granular non-blood tinged hard stools. She wasbrought to a local practitioner where abdominal fullness associated with stool impaction was suspected, but she had a poor response to treatment. Later dysuria and oliguria were found. So she came to our emergency room where the Lab data showed: WBC:29,500/ul, Seg/Lym/Mono:66/20/12.5%, CRP:136mg/L; U/A: WBC:30~40, bacilli:3+, nitrite +, leukocyte esterase +. Physical examination showed 1)bilateral coarse breathing sound 2)soft abdomen and hyperactive bowel sound, no tenderness, no rebounding pain and no costophrenic angles knocking pain. Under the impression of UTI with mild dehydration, she was admitted to our ward for further evaluation and treatment.
Past History:
Admission history: none
Operation history:none
Personal History:
Birth Hx: G1P1, GA: 39weeks, Birth body weight2800gm, delivered via C/S
Vaccination Hx:
Birth: BCG(+) HBV #1 (+ )
1 months: HBV #2
2 months: DTaP#1, OPV #1
4 months: DTaP#2, OPV #2
6 months: DTaP#3, OPV #3
12 months: MMR #1, Varicella
15 months: JBE #1, JBE #2
18 months: DTaP-Hib-IPV #4 (5合1 ), HepA #1
Growth Hx:
BW: 15 kg (97th percentile) BL: 98 cm (97th percentile)
Developmental milestones:
Gross motor:
Raises head(1m/o), Lifts chest (2m/o), Supports on forearms (3m/o), Rolls over(4m/o), Sits unsupported(7m/o)
Sits well, Crawls or creeps on hands and knees (9m/o), May walk 1 or 2 steps without support (12m/o),
Creeps up stairs, walks backward(15m/o), Runs, throws objects from stand(18m/o), Up and down stairs(24m/o)
Visual/fine motor
Tight grasp, follows to midline(1m/o), Fists no longer clenched, follows past midline(2m/o), Responds to visual threat(3m/o), Reaches with both arms in unison(4m/o), Unilateral reach, transfers objects(7m/o), Immature pincer grasp, throws objects (9m/o), Mature pincer grasp (12m/o), throws objects(15m/o), 2-block tower(15m/o), scribbles3-block tower(18m/o),7-block tower, undresses (24m/o),
Language
Alerts to sound(1m/o), Social smile(2m/o), Coos(3m/o), Laughs, orients to voice(4m/o), Babbles, razzes(7m/o), "mama" and "dad" indiscriminately(9m/o), 2 words besides "mama/dada"(12m/o), 4-6 words(15m/o), 7-10 words, knows 5 body parts(18m/o), 50 words, 2-word sentences(24m/o),
Social
Looks at faces(1m/o), Recognizes parent(2m/o), Reaches for familiar people(3m/o), Enjoys looking around(4m/o), Recognizes that a person is a stranger(7m/o), Pat-a-cake, explores(9m/o), Imitates, comes when called912m/o), uses spoon and cup(15-18m/o), Plays in group(18m/o), Parallel play(24m/o),
Impression:
Fever with pyuria, suspect urinary tract infection
Differential diagnosis:
Acute pyelonephritis
Plan:
(1) Diagnostic plan:
1.Perform urine culture & wait for the result
2.Follow the result of blood culture for suspect urosepsis
3.Arrange renal echo or DMSA for suspected acute pyelonephritis if needed
(2) Therapeutic plan:
1.Antibiotic with Cefazolin and Gentamycin
2.Intravenous fluid hydration
3.Follow up urinalysis before discharge
(3) Education plan:
1.Teach the parents to guide the child to empty bladder once every 3-4hrs
2.Finish the full course of antibiotics
3. Encourage the p’t to drink plenty of fluids during the day.
4.Teach about general hygiene of the external genital organ.
二.【Croup】
主訴:
Hoarseness and barking cough since last night.
現病史:
The 1-yar-old girl has suffered from fever off and on with body temperature around 38-38.5 degrees C for 3 days. Cough and rhinorrhea have been also noted. She had visited a pediatric clinic with little improvement. Hoarseness and barking cough have developed since last night. Therefore, she was brought to our emergency room. Physical examination revealed injected throat, mild suprasternal and subcostal retraction with inspiratory stridor. Chest x-ray was performed and revealed steeple sign and hyperinflation of bilateral lung fields. Under the impression of Croup, she was admitted to our ward for further evaluation and management.
住院主要臆斷
Croup
鑑別診斷：
Epiglottitis
Retropharyngeal abscess
住院診療計住院診療計劃:
1.診斷計劃
(1)Check Mycoplasma pneumonaie Ab
(2)Check pneumococcus rapid screen (urine)
(3)Check lateral neck X ray to R/O epiglottitis if needed.
2.治療計劃:
(1) Steroid for anti-inflammatory effect
(2) Inhalation with racemic epinephrine for one day
(3) Oxygen tent with cool humidification
(4)Pulse oximetor if respiratory distress is suspected
3.衛教及告知計劃:
(1) If shortness of breath or cough become more severe, go back into O2 tent and
if not improve immediately inform nurse or doctor.
三.【Herpangina】
主訴:
Fever up to 39 degrees C for 1 day
現病史:
This 9-month-old little boy presented with fever up to 39C and poor feeding for 1 day. There was no obvious skin rash on his hands, feet,or buttocks. Decreased activity and mild cough with rhinorrhea were noted by his family. There was no myoclonic jerks found during this illness. He was sent to our ED where physical examination revealed injected throat with enlarged tonsils and multiple ulcerated vesicles on the soft palate. Under the impression of herpangina and due to poor feeding, he was admitted to our ward for further evaluation and treatment.
住院主要臆斷:
Herpangina with poor feeding
鑑別診斷:
Hand-footmouth disease or Gingivostomatitis
住院診療計劃:
1.Diagnostic plan:
(1) Virus culture, enterovirus 71 PCR if disease progression is noted.
(2) CSF study will be checked if covulsions, abnormal behavior, and
conscious disturbance if found.
(3) CK-MB & Troponin-I will be checked if tachycardia is noted, for suspected myocarditis.
2.Theraptic plan:
(1)Intravenous fluid supply for poor oral intake.
(2)Analgesics for sorethroat.
(3)Close monitoring for signs of possible disease progression.
3.Educational plan:
(1).Frequent handwashing and good hygiene to reduce the risk of enteroviral transmission.
(2) Eat a non-irritating diet. (such as: cold milk, ice cream, jelly, pudding)Avoid spicy, fried, or hot foods.
四. 【Acute exudative tonsillitis】
主訴:
Fever off and on for 5 days
現病史:
According to the family, this 7-year-old boy has suffered from fever off and on with temperature around 38.5-39 degrees C for 5 days. Sorethroat and poor appetite were also noted. He had visited a local pediatric clinic, but the intermittent fever persisted.Abdominal pain and skin rash have developed since yesterdaymorning. Therefore, he was brought to our emergency room. Physical examination revealed injected throat, swollen tonsils with whitish coating. Mild tenderness over the abdomen right upper quadrant and erythematous maculopapular rash over trunk were also noted. The laboratory examiantion revealed W.B.C. 19,400/uL, CRP 87.5 mg/L. Under theimpression of acute exudative tonsillitis, he was admitted to our ward for further evaluation and treatment.
住院主要臆斷:
1.Acute exudative tonsillitis
2.Abdominal pain, r/o hepatitis
住院診療計劃:
1.診斷計劃
(1)Check SGOT, SGPT for suspect hepatitis.
(2)Arrange abdomen echo if abdominal pain persist.
(3)Check EB-VCA IgG & IgM ; Adenovirus IgG & IgM
(4)Perform throat culture for suspect group A streptococcus infection
2.治療計劃:
(1) Intravenous hydration supply for poor oral intake
(2)Antibiotic with Aq-penicillin for suspect bacterial infection.
(3) Analgesics for sore-throat if clinically indicated.
(4) Close monitoring of fever curve & adjust treatment as clinically indicated.
3.衛教及告知計劃:
(1) Complete the full course of antibiotic therapy, if it is bacterial tonsillitis
(2) Avoid contact sports for 6 weeks if EBV infection is confirmed, because of the possibility of spleen rupture.
(3)Eat soft food and drink cool beverages or warm liquids.
五. 【Pneumonia】
主訴:
Intermittent fever and productive cough for 4 days
現病史:
According to her parents,this 7-year-old girl has suffered from fever since 4 days ago and aggravated productive cough since 2 days ago. Skin rash and abdominal pain had been noted last week and had decreased gradually. She had been brought to a local clinic where virus infectionrelated skin rash was told. Recently, on and off fever has been noticed for the past 4 days. Productive cough with yellowish sputum and nocturnal cough were also found. So she was brought to Dr楊宏義pediatric clinic where some medications and instructions for keeping close observation for any deterioration were given. Since the fever persisted and chest wall pain withaggravated cough was noted, she was brought to our emergency room for further care.
At our emergency room, physical examination revealed injected throat and coarse breath sounds with poor air entry over the right lung fields. Lab data revealed marked leukocytosis and elevated CRP. The CXR showed a patchy infiltrates over the right lower lung with blurring of the right heart border. She wasadmitted under the impression of pneumonia for further evaluation and treatment.
住院主要臆斷:
Pneumonia, right lower lobe
住院診療計劃:
1.診斷計劃
(1)Check Mycoplasma pneumonaie Ab
(2)Check pneumococcus rapid screen (urine)
(3)F/U CXR if clinical condition deteriorates
2.治療計劃:
(1) Intravenous hydration supply for poor oral intake
(2) Antibiotic with Cefazolin for suspect bacterial pneumonia due to leukocytosis & elevated CRP
(3) Add Erythomycin if the Mycoplasma pneumoniae Ab reveals >= 1:160
(4) Inhalation with bronchodilator and mucolytic agents
(5)Chest physiotherapy
3.衛教及告知計劃:
(1) To complete the full course of antibiotic therapy
(2) Practice good hygiene: to wash their hands before eating and after using the toilet.
(3)Get vaccination, such as pneumococcus, influenza vaccines.
(4) To drink more warm water, get plenty of rest, and eat a healthy diet that includes fruits, vegetables and whole grain food.
六.【Hyperbilirubinemia】
主訴:
Yellowish skin with poor activity for 1 day
現病史:
This 2-day-old female infant was born via vaginal delivery to aG1P1 mother at the gestational age of 38 weeks. The Apgar score at 1 and 5 minutes were 8 and 9 and the birth body weight was 3209 gm. The prenatal examination and maternal history were of no special significance except that the maternal vaginal culture yielded group B streptococcus species (moderate) for which the mother had received antibiotic therapy. The baby was breastfed and the sucking power and urine output were fair. Icteric skin was noted this morning. Capillary bilirubin values was checked and revealed 16 mg/dL. Under the impression of neonatal hyper-bilirubinemia, she was transferred to our sick baby nursery room forfurther evaluation and management.
住院主要臆斷:
Neonatal hyper-bilirubinemia
住院診療計劃:
1.Diagnostic plan:
(1) Coomb's test, G-6PD, Bil T/D, Blood typing, Reticulocyte count, RBC
Morphology for work up of hyperbilirubinemia.
2.Theraptic plan:
(1) Phototherapy
(2) Intravenous fluid supply for phototherapy.
(3) Recheck total bilirubin level regularly and adjust phototherapy accordingly.
3.Educational plan:
(1)Encourage continue breast feeding
(2) Monitor color of stool and activity of newborn.
七.【Respiratory distress】
主訴:
Shortness of breath since birth
現病史:
This newly born female infant was born to a G1P1 Mom at the gestational age of 38 weeks via Cesarean section. The Apgar score at 1 and 5 minutes were 8 and 9 and the birth body weight was 3118 gm. The prenatal examination and the maternal history were notsignificant Tachypnea with grunting was noted in our baby room soon after birth. Physical examination revealed tachypnea, intercostals, subcostal retraction, rales breathsounds, and a grade II/VI systolic ejection heart murmur over the LLSB. Under the impression of respiratory distress, suspected TTNB, suspected pneumonitis, R/O congenital heart disease, she was transferred to our sick baby nursery room for further evaluation and treatment.
住院主要臆斷:
Respiratory distress
Suspect Transient Tachypnea of Newborn
Suspect pneumonitis
R/O congenital heart disease
住院診療計劃:
1.Diagnostic plan:
(1) CBC/DC, CRP, blood culture, urine GBS Ag due to suspect perinatal infection
(2) Perform chest x-ray and arterial gas due to respiratory distress
(3) Arrange echocardiogram to r/o congenital heart disease
2.Theraputic plan:
(1) NPO due to respiratory distress
(2) Intravenous fluid supply and check dextrose prn
(3) Antibiotic with Ampicillin and Gentamycin due to possible perinatal infection
3.Educational plan: (1)Inform the family about possible complication & causes of respiratory distress.
(2)Start feeding with breast milk if the respiratory symptom improves.
(3)Encourage the mother to express and freeze the breastmilk so the newborn will have breast milk to feed when she is ready.
八【Acute gastroenteritis with mild dehydration】
主訴:
Fever and diarrhea with blood-tinged and mucoid stool for 3 days
現病史:
The 3-year-old girl has suffered from fever off and on with body temperature around 39-39.5 degrees C for 3 days. Diarrhea with blood -tinged mucoid stools 7-8 times per day accompanied with intermittent abdominal pain developed 3 days ago. Poor appetite and decreased activity were also noted. Additionally, her parents mentioned that the girlhas urinated less frequently with dark yellow urine since yesterday. She was brought to our outpatient department today. Her parents denied any recent travel history but they had fed her some eggs and seafood prior to this event. Physical examination revealed dry oral mucosa, tenderabdomenwith hyperactive bowel sound but no reboundingpain. Under the impression of acute gastroenteritis with mild dehydration, she was admitted to our ward for further evaluation and management.
住院主要臆斷:
Acute gastroenteritis with mild dehydration
鑑別診斷：
Bacterial enterocolitis
Intussusceptions
Acute appendicitis
住院診療計住院診療計劃:
1.診斷計劃
(1)CBC/DC, CRP, electrolyte, blood culture, stool routine, Rotavirus Ag, stool culture
(2)Abdominal echo or KUB if condition deteriorates
2.治療計劃:
(1) Intravenous fluid supply for mild dehydration
(2) Antidiarrhea agents & Probiotics
(3)Close monitoring of clinical condition and adjustment of treatment as needed, such as adding antibiotics.
3.衛教及告知計劃:
(1)Light diet
(2) Good handwashing before eating and whenever handling food or stools.
九.【Acute gastroenteritis with mild dehydration】
主訴:
Abdominal pain for 3 days
現病史:
The 2-year-6-month-old girl has suffered from intermittent colicky abdominal pain in peri-umbilical area for 3 days. No exacerbating or alleviating factors were mentioned. No URI symptoms were found.Her parents noticed some irritability, decreased appetite, emesis twice, and one episode of diarrhea with blood and mucus today.Therefore, she was brought to our emergency room. Physical examination revealed dry oral mucosa, tender abdomen but no definite rebound pain with some hyperactive bowel sound.Under the impression of acute gastroenteritis with mild dehydration, she was admitted to our ward for further evaluation and management.
住院主要臆斷:
Acute gastroenteritis with mild dehydration
鑑別診斷：
Intussusceptions
Acute appendicitis
住院診療計住院診療計劃:
1.診斷計劃
(1)Abdominal echo if abdominal pain persist
(2)Barium-contrast enema if intussusceptions is suspected.
2.治療計劃:
(1)Intravenous fluid hydration
(2)NPO if vomiting and diarrhea is severe.
(3) Close monitoring of clinical condition and adjustment of treatment as needed.
(4) Symptomatic treatment with anti-emetic drugs
3.衛教及告知計劃:
(1) Eat a light diet with less oil or fats.
(2) Keep records of intake and output.
(3) Instruct family to inform the nurse or doctors of any aggravation of symptom or signs of intussusceptions. such as:
severe abdominal pain
persistentvomiting
blood and mucus in faeces: currant jelly stool
toxic appearance
十. 【Periorbital cellulitis】
主訴:
Left eyelid swelling since this noon
現病史:
The 14-year-old boy, without systemic disease, suffered from persistent headache 1 week ago over bilateral occipital and frontal region. Fever up to 39'C, non-productive cough, rhinorrhea, and nasal stiffness were also noted later that day, so he visited a local clinic. Common cold was told and symptomatic treatment was given. The URI symptoms persisted with some improvement of headache and fever. The fever recurred 2 days ago and he went back to the clinic again but there was no relief of symptom. Left eyelid swelling was also noted since this afternoon, so hecame to our hospital for further help. He also mentioned about the habit of rubbing his eyes, but denied any recent trauma or insect bite around the left eye.
主要臆斷：
Left periorbital cellulites
鑑別診斷：
Orbital cellulites
Mastoiditis
Sinusitis
住院診療計住院診療計劃:
1.診斷計劃
(1) Pus culture of eyedischarge
(2)CBC/DC, CRP, blood culture
(3) Skull x-ray : Water view for R/O sinusitis
2.治療計劃:
(1)Intravenous fluid supply
(2)Antibiotics for possible bacterial periorbital cellulitis
(3)Ophthalmologic consultation
3.衛教及告知計劃:
(1)Explain to the patient and parents of the nature, course, expected time of treatment and outcomes of disease
(2) Inform the patient and family that loss of vision, diplopia or pain with eye movements is an indication that the infection may have spread to the orbit and may necessitate surgical intervention.
(3) Avoid contact with the eye and wash hands often.