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According to the patient's family, this 7y/o boy was quite healthy before.
根據病人家屬說這個 7 歲的小男孩以前非常健康,
He had cough for 2~3 days before admission, and fever for 1 day, and sore throat.
Then, heavy sputum, rhinorrhea, developed. Poor appetite and decreased activity were noted by the family.
然後濃痰、流鼻涕嚴重的。由家人注意到食慾差和活動力降低情形確診 B 型流感陽性。
Influenza B positive diagnosed today. Due to reflactory fever, he was sent to our emergency department.
由於難治療的發燒,他被送到我們的急診。
Under the impression of Influenza infection R/O bronchopneumonia, he was admitted to our ward for further evaluation and management.
在診斷感染流感之前疑似支氣管肺炎,他住進我們病房做進一步評估和管理。
<Birth history> G5P3A2, NSD, BBW: 2845gm, GA:38+1/7 weeks, Apgar Score:8'-->9'
分娩史 孕次/產次/流產自然產 出生體重 妊娠周數 阿帕嘉計分數:8-9
<Vaccination history> BCG (yes), HBIG (no), HBV (1+2+3), DPT+IPV+Hib (1+2+3),
麻疹腮腺炎德國麻疹水痘疫苗 流感疫苗肺炎鏈球菌疫苗
<Allergic history> No drug or food allergy , (+) atopic illness 過敏史 沒有藥物或食物過敏 過敏性疾病陽性
●【FAMILY HISTORY】家族病史
non-contributory 沒有別的發現
●【SYSTEM REVIEW】一般身體檢查
=General:
Fever(+)發燒 Chills(-)畏寒 BW loss(-)體重減輕 Fatigue(+) 疲倦感 Slurred speach(-) 言語不清 Anemia(-)貧血 Sweating(-) 出汗
=Skin:皮膚
=Eyes: 眼睛
=ENT: 耳鼻喉
Pain(-)疼痛 Discharge(+)分泌物 Tinnitus(-)耳鳴 Deafness(-) 耳聾 Sinusitis(-) 鼻竇炎
Epistaxis(-) 鼻出血 Postnasal drip(-)鼻涕倒流 Hoarseness(-) 嘶啞 Vertigo(-)眩暈 Facial pain & sores(-) 面部疼痛潰瘍
Mental status: 精神狀態 E4V5M6 眼睛/言語/動作, Nutritional status: well nourished 營養狀況:良好的營養
Lung 肺: breath sounds: VBS (+) over both lungs field, 呼吸音腹式呼吸在兩側肺部領域
coarse,rales(-)無粗囉音,wheezing(-)無喘鳴音
Hear 心 t: regular heart beat,no murmur,no thrill nor heave 規律心跳無心雜音 無震顫也無鼓出
Abdomen 腹部: soft 柔軟, flat,non-tender,平坦 no hepatosplenomegaly, 無壓痛 normoactive bowel sounds 無肝脾腫大無明顯腸音/正常腸音
●【LAB DATA】實驗數據
【血液】------------------------------------------------------------------------
項 目: MCH 平均血紅素 MCHC 平均血紅素容積比 Platelet 血小板 cou Neutro 嗜中性白血球 Lym 淋巴球
日 期(時間) % % % % %
項 目: Metamyelo 後骨髓細胞 Myelo 骨髓細胞 Pro 前骨髓細胞 Blast 母細胞 NRBC 有核紅血球
日 期(時間) % % % % /100WBC
【生化】------------------------------------------------------------------------
日 期(時間) mg/dl
1050313(1108) 1.10
【血清】------------------------------------------------------------------------
日 期(時間) * *
1050313(1009) Negative 陰性 Positive 陽性
【鏡檢】------------------------------------------------------------------------
檢 體:《Urine-midstream》 中段尿
1050313(1113) - - - -
項 目: Sp.gr (specific 尿比重 OB 潛血 PH 酸鹼值 Protein 尿蛋白
日 期(時間) mg/dL * ul
1050313(1113) (Normal)<1.5 - -
●【IMPRESSION】臆斷
Dehydration 脫水
●【PLANNING】計畫
J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia
流感由於具有其他相同的流行感冒病毒與肺炎性流行感冒病毒。