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
but no rhinorrhea. Her mother also noted that she had poor appetite, vomiting
and constipation with small granular non-blood tinged hard stools. She was
brought 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 weight 2800gm, 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)
Developmental milestones:
BL: 98
cm (97th percentile)
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-foot & mouth disease or Gingivostomatitis
住院診療計劃:
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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. Sore throat 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 yesterday morning. 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 the
impression 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 infection related 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 with aggravated 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
was admitted 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 a G1P1 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 for further 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.
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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 not significant Tachypnea with grunting was noted in
our baby room soon after birth. Physical examination revealed tachypnea,
intercostals, subcostal retraction, rales breath sounds, 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
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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 breast milk 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 girl has 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, tender abdomen with hyperactive bowel sound but
no rebounding pain. 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 hand washing 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
persistent vomiting
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 he came 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 eye discharge
(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.