《儿科学》课程作业习题（典型病例）02 pneumonia

Medical Number: 630945Diagnosis: bronchial pneumoniaHistory summary1. Jixx, female, I year and 6months old.2. Chief complaints: fever and cough for 5 days, and getting worse for 3 dayshcourse was short4. Five days before admission, the patient began to cough and felt short of breath withoutwheezing. Three days ago, the situation became more and more worse. During the course, thepatient had an intermitent high-grade fever (peak temperature, 39.5°C), without vomiting,convulsion and rash. Since onset, the spirit was fair while appetite was poor. The stool wasformless and urine was norma4.Nospeciahis5. Physical examination:T:37CP:128/minR46/minNasal flaringandretractionsignwerenotseen.Cyanosis around mouth wasobvious.Auscultation ofthechest revealed moderate and minorrales in the lung.Cardiac sound was powerful, and rhythmwas regular.Abdomen was soft.Therewasnocvisofthenailbeo6. LabChestmediann band.(picture1)adiograpSputum culture: normal floraice of the respiratory virus: respiratory syncytial virus (+).ImmunofluoresTreatmenwas to maintain adequate oxygen saturation levels, and sputuSupploxvgeaspiration was to keep the respiratory tract clear.Cephalosporin was administered intravenouslyand nubulized Mucosolvin wasgiven alsoOutcomeAfer the treatment, the patient's fever disappeared within 24 hours. Cough was relieved, andshort of breath was improved. The hypoxia and the rales diminished graduallyWhen the patient was discharged, he had nofever and wheezing, justalitle cough The spiritWas well and apetite was god.Physical examination: T 36.7CP122/minR35/min,Thegeneralconditionwasgood.Cyanosiswasnot senAuscultationofthechestrevealed noralesithelung.Cardiac sound was powerul, andrhythm wasregular.Abdomen was soft.There wasncyanosis of thenail bedFollow-uVisit thee cough and the physical signs of the lung for 1 week. If necessary, recheck the Chradiograph

Medical Number: 630945 Diagnosis: bronchial pneumonia History summary: 1. Ji xx, female, 1 year and 6 months old. 2. Chief complaints: fever and cough for 5 days, and getting worse for 3 days. 3. The onset was urgent, and the course was short. 4. Five days before admission, the patient began to cough and felt short of breath without wheezing. Three days ago, the situation became more and more worse. During the course, the patient had an intermittent high-grade fever (peak temperature, 39.5°C), without vomiting, convulsion and rash. Since onset, the spirit was fair while appetite was poor. The stool was formless and urine was normal. 4. No special personal history. 5. Physical examination: T:37℃ P:128/min R46/min. Nasal flaring and retraction sign were not seen. Cyanosis around mouth was obvious. Auscultation of the chest revealed moderate and minor rales in the lung. Cardiac sound was powerful, and rhythm was regular. Abdomen was soft. There was no cyanosis of the nail bed. 6. Laboratory values: Chest radiograph: there were patches in the inner and median band. （picture 1） Sputum culture: normal flora. Immunofluorescence of the respiratory virus: respiratory syncytial virus (+). Treatment: Supplemental oxygen was to maintain adequate oxygen saturation levels, and sputum aspiration was to keep the respiratory tract clear. Cephalosporin was administered intravenously， and nubulized Mucosolvin was given also. Outcome: After the treatment, the patient's fever disappeared within 24 hours. Cough was relieved, and short of breath was improved. The hypoxia and the rales diminished gradually. When the patient was discharged, he had no fever and wheezing, just a little cough. The spirit was well and appetite was good. Physical examination: T 36.7℃ P 122/min R 35/min. The general condition was good. Cyanosis was not seen. Auscultation of the chest revealed no rales in the lung. Cardiac sound was powerful, and rhythm was regular. Abdomen was soft. There was no cyanosis of the nail bed. Follow-up: Visit the cough and the physical signs of the lung for 1 week. If necessary, recheck the Chest radiograph

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