《醫(yī)學(xué)英語實(shí)用情景教程》（徐青） Unit 4 Pediatrics 兒科

醫(yī)學(xué)英語實(shí)用情景教程Unit4Pediatrics兒科知識(shí)目標(biāo)掌握兒科常見疾病的英文術(shù)語。掌握詢問、描述兒科常見疾病的相關(guān)英文表達(dá)。掌握兒科英文病歷的寫法。技能目標(biāo)能用英語與兒科患者溝通。能讀懂兒科相關(guān)的英文病歷。思政目標(biāo)不斷探索相關(guān)知識(shí)與技能，從理論中感悟?qū)嵺`，樹立“我是祖國(guó)的一個(gè)小細(xì)胞，祖國(guó)的發(fā)展需要大家共同努力”的觀念。項(xiàng)目目標(biāo)1．學(xué)習(xí)“知識(shí)儲(chǔ)備”中的內(nèi)容，掌握本單元的重點(diǎn)醫(yī)學(xué)術(shù)語和常用表達(dá)。2．跟讀“醫(yī)患交流”下的英文對(duì)話，然后角色扮演各對(duì)話場(chǎng)景。3．仔細(xì)閱讀“病歷閱讀”下兒科相關(guān)的英文病歷，總結(jié)其中重點(diǎn)句型及詞匯。4．完成本單元的“任務(wù)檢測(cè)”。5．根據(jù)以上任務(wù)的完成情況，給自己評(píng)分。任務(wù)描述目錄123知識(shí)儲(chǔ)備醫(yī)患交流病歷閱讀章節(jié)導(dǎo)航01知識(shí)儲(chǔ)備CommonDiseasesofPediatricsKeyWordsandExpressionsModelSentencesCommonDiseasesofPediatrics新生兒疾病neonatalpneumonia /?ni????ne?tlnju?'m??n??/ 新生兒肺炎o(hù)mphalitisofnewborn /?ɑmf?'la?t?s?v'nu?b??rn/ 新生兒臍炎neonataljaundice /?ni???'ne?tl'd???nd?s/ 新生兒黃疸convulsionofnewborn /k?n'v?l??n?v'nu?b??rn/ 新生兒驚厥neonatalsepticemia /?ni???'ne?tl?sept?'s?m??/ 新生兒敗血癥tetanusneonatorum /'tet?n?s?ni??'ne?t??r?m/ 新生兒破傷風(fēng)CommonDiseasesofPediatrics兒科血液系統(tǒng)疾病nutritionalmacrocyticanemia /nj?'tr???nl?m?kr??'s?t?k?'n?m??/營(yíng)養(yǎng)性大細(xì)胞性貧血aplasticanemia /e?'pl?st?k?'n?m??/再生障礙性貧血infectiousmononucleosis/?n'fek??s?m?n?(?)nju?kl?'??s?s/傳染性單核細(xì)胞增多癥CommonDiseasesofPediatrics兒童傳染性疾病measles /'m?z?lz/ 麻疹rubella /ru??bel?/ 風(fēng)疹Germanmeasles /'d???m?n'm?z?lz/ 德國(guó)麻疹；風(fēng)疹varicella /?v?r?'sel?/ 水痘chickenpox /?t??k?np?ks/ 水痘roseolainfantum /?r??z?'??l??n'f?nt?m/ 嬰兒玫瑰疹，奶麻CommonDiseasesofPediatrics兒童傳染性疾病exanthemsubitum /ek's?nθ?msju?'b?t?m/ 幼兒急疹epidemicparotitis /?ep??dem?k?p?r??ta?t?s/ 流行性腮腺炎mumps /m?mps/ 腮腺炎bacillarydysentery /'b?s?l?r?'d?s(?)nt(?)r?/ 細(xì)菌性痢疾viralhepatitis /'va?r?l?hep??ta?t?s/ 病毒性肝炎

CommonDiseasesofPediatrics兒童消化系統(tǒng)疾病thrush /θr??/ 鵝口瘡hand,footandmouthdisease 手足口病stomatitis /?st??m?'ta?t?s/ 口腔炎gastroesophagealreflux /?ɡ?str???'sɑf??d???l'r??fl?ks/ 胃食管反流infantilediarrhea /'?nf?nta?l?da??'r??/ 小兒腹瀉CommonDiseasesofPediatrics其他常見疾病Kawasakidisease /?kɑ?w?'sɑk?d?'z?z/ 川崎病childepilepsy /t?a?ld?ep?leps?/ 小兒癲癇viralencephalitis /'va?r?len?sef??la?t?s/ 病毒性腦炎viralmeningitis /'va?r?l?men?n?d?a?t?s/ 病毒性腦膜炎hyperkineticsyndromeofchildhood/?ha?p?ka?'net?k's?ndr?m?v't?a?ldh?d/ 兒童多動(dòng)綜合征vitaminDdeficientrickets /?v?t?m?nd?d?'f??nt'r?k?ts/ 維生素D缺乏性佝僂病primarypulmonarytuberculosis /'pra?m?r??p?lm?n?r?tju??b??kj??l??s?s/ 原發(fā)型肺結(jié)核ascariasis /??sk??ra??s?s/ 蛔蟲病KeyWordsandExpressions產(chǎn)科疾病aundice /?d???nd?s/ n. 黃疸recede /r??s?d/ v. 后退；減弱bilirubin /?b?l??ru?b?n/ n. 膽紅素normalvalue /?n??m?l?v?lj?/ 正常值physiologic /?f?z??'l?d??k/ adj. 生理的pathological /?p?θ??l?d??kl/ adj. 病理學(xué)的lesion /?l???n/ n. （因傷病導(dǎo)致皮膚或器官的）損傷，損害gum /g?m/ n. 牙齦；齒齦；牙床sorethroat /s??θr??t/ 喉嚨痛intermittent ??nt??m?t?nt/ adj. 斷斷續(xù)續(xù)的；間歇的KeyWordsandExpressions產(chǎn)科疾病cramp /kr?mp/ n. 痛性痙攣，抽搐symptom /?s?mpt?m/ n. 癥狀；征兆makeadiagnosis /me?k??da??g?n??s?s/ 診斷saliva /s??la?v?/ n. 唾液prognosis /pr?g?n??s?s/ n. （對(duì)病情的）預(yù)斷，預(yù)后complication /?k?mpl??ke??n/ n. 并發(fā)癥outpatientclinic /?a?tpe??nt?kl?n?k/ 門診部penicillin /?pen??s?l?n/ n. 青霉素；盤尼西林humidifier /hju??m?d?fa??(r)/ n. 加濕器moisten /?m??sn/ v. 使潮潤(rùn)，使?jié)駶?rùn)KeyWordsandExpressions產(chǎn)科疾病lastbutnotleast 最后但同樣重要的是spoil /sp??l/ v. 變質(zhì)；變壞；腐敗formula /?f??mj?l?/ n. 配方奶（母乳的替代品）waterystool /'w??t(?)r?stu?l/ 水樣便mucous ?mju?k?s/ n. 黏液；鼻涕parturition /?pɑ?tj??r??n/ n. 分娩cesarean /s??ze?r??n/ n. 剖宮產(chǎn)tract /tr?kt/ n. 連通身體組織或器官的道infantileenteritis /??nf?nta?l?ent??ra?t?s/ 小兒腸炎intestinalflora /?n?test?n?l?fl??r?/ 腸道菌群ModelSentences1.Forthebilirubinleveldidn’texceedthenormalvalue,thedoctoradvisedustofeedthebabyfrequently,baskthebabyinthesunshinemoreandpayattentiontothebaby’sskincolor.當(dāng)時(shí)由于黃疸值沒有超標(biāo)，醫(yī)生建議我們讓孩子多吃多拉、多曬太陽，并注意觀察孩子皮膚的顏色。3.Don’tworry,thebilirubinlevelisinthenormalrange.不用擔(dān)心，黃疸值在正常范圍內(nèi)。2.Itseemedthathisskinwasn’tasyellowasbefore.似乎他的皮膚沒有之前黃了。ModelSentences4.Ifoundthereweresomerashesontheskinofherhandsandfeet,andshelookedverytired.昨天我發(fā)現(xiàn)她手上和腳上出了皮疹，并且精神狀態(tài)很差。5.It’sakindofcontagiousdiseasethatmainlyhappensinchildren.這是一種傳染性疾病，主要發(fā)生在小孩身上。7.Doesshehaveanydifficultyinbreathingorcomplaintsofchestpains?她呼吸困難嗎？胸痛嗎？6.Sheneedsnospecialtreatment.她不需要接受特殊治療。ModelSentences8.Don’tworry.Mostchildrenmakeacompleterecoveryfrompneumonia.別擔(dān)心，大多數(shù)得肺炎的孩子都能完全康復(fù)。9.Ahumidifierwillhelpmoistentheairandmayhelpyourchildbreathebetter.在房間里使用加濕器可以幫助她更好地呼吸。11.Howfrequently?一天幾次？10.Ifherconditiongetsworse,bringherbackanytime.如果孩子病情惡化，隨時(shí)帶她來就診。ModelSentences12.Whatkindofstooldidyounotice,wateryormucous?大便是什么樣的？水樣便還是黏液樣便？13.Issheloosingweight?體重下降了嗎？14.Whatabigrelief!我總算放心了！課堂小結(jié)這小結(jié)我們學(xué)習(xí)了兒科醫(yī)學(xué)中的常見病、關(guān)鍵詞和表達(dá)式和模型句子。希望大家能加深對(duì)英語詞匯的理解并靈活應(yīng)用。02醫(yī)患交流Conversation1NeonatalJaundice新生兒黃疸Conversation2Hand,FootandMouthDisease手足口病Conversation3ChildPneumonia兒童肺炎Conversation4Diarrhea腹瀉Conversation1NeonatalJaundice新生兒黃疸P:Morning,doctor.D:Morning,sitdown,please.Itseemsthatyourbabystillhasjaundice.P:Heisonemonthold,butjaundicehasn’trecededyet.D:Tellmeabouthiscondition.P:Hisskinturnedyellowobviouslythreedaysafterhisbirth.Forthebilirubinleveldidn’texceedthenormalvalue,doctoradvisedustofeedthebabyfrequently,baskthebabyinthesunshinemoreandpayattentiontothebaby’sskincolor.D:Howdidyourbaby’sskinlooklikeafterleavingthehospital?家長(zhǎng)：早上好，大夫。醫(yī)生：早上好，請(qǐng)坐。似乎你孩子的黃疸還沒有退。家長(zhǎng)：我的寶寶已經(jīng)滿月了，但是黃疸一直沒有退。醫(yī)生：跟我講講你寶寶的情況。家長(zhǎng)：他出生3天后皮膚明顯變黃，當(dāng)時(shí)由于黃疸值沒有超標(biāo)，醫(yī)生建議我們讓孩子多吃多拉、多曬太陽，并注意觀察孩子皮膚的顏色。醫(yī)生：出院后你寶寶的皮膚看起來怎么樣？Conversation1NeonatalJaundice新生兒黃疸P:Itseemedthathisskinwasn’tasyellowasbefore.Butjaundicehasn’trecededcompletely.D:Isee.Takeyourbabytothenurseandcheckthejaundicelevelfirst.P:OK.D:Don’tworry,thebilirubinlevelisinthenormalrange.Ithinkit’sphysiologicjaundice,notapathologicalone.P:Butwhydoesitlastforsuchalongtime?D:Insomespecialcasesittakesabout40to50daystorecedecompletely.P:Thankyouverymuch.家長(zhǎng)：似乎他的皮膚沒有之前黃了。但黃疸還沒有完全退掉。醫(yī)生：知道了，讓護(hù)士幫你的寶寶量一下黃疸。家長(zhǎng)：好的。醫(yī)生：不用擔(dān)心，黃疸值還在正常范圍內(nèi)，應(yīng)該是生理性黃疸，不是病理性的。家長(zhǎng)：但是為什么會(huì)持續(xù)這么長(zhǎng)時(shí)間呢？醫(yī)生：在特別的情況下，需要四五十天才能退完。家長(zhǎng)：非常謝謝你。Conversation2Hand,FootandMouthDisease

手足口病D:Goodmorning.Sitdown,please.Whatistroublingyourbaby?P:Goodmorning,doctor.Mybabyisnotverywell.D:Takeiteasy.Tellmemoredetails.P:YesterdayIfoundthereweresomerashesontheskinofherhandsandfeet,andshelookedverytired.D:Letmesee.Therearealsored,blister-likelesionsonthetongue,gumsandinsideofthecheeks.Doesshehaveafeveroraheadacheorapainintheselesionsofskin?P:Yes,shehasasorethroatwhensheiseatingandanintermittentfeverashighas39.2degrees.D:Hasshevomitedorgotacramp?醫(yī)生：早上好，請(qǐng)坐。你的寶寶怎么了？家長(zhǎng)：早上好，大夫。我的寶寶不太舒服。醫(yī)生：別著急，告訴是我怎么回事。家長(zhǎng)：昨天我發(fā)現(xiàn)她手上和腳上出了皮疹，并且精神狀態(tài)很差。醫(yī)生：我看一下。她的舌頭上、牙齦上和面頰內(nèi)側(cè)也有一些紅色的、水泡狀的潰瘍。她還有其他不適嗎？比如發(fā)燒、頭痛、損傷部位疼痛。家長(zhǎng)：她進(jìn)食時(shí)有咽喉痛，間歇性發(fā)熱，體溫最高達(dá)到了39.2度。醫(yī)生：她有沒有嘔吐或者抽搐？Conversation2Hand,FootandMouthDisease

手足口病P:No.D:Whataboutherappetiteandsleep?P:Shehasapoorappetiteandeatsashalfasnormal.Shedidn’tsleepwelllastnight.D:Didshecontactwithotherkidswhohavesimilarsymptoms?P:Someofherclassmatesinherkindergartenhadsimilarsymptomsandmydaughterplayedgameswiththem.Buttheyhaverecoveredwithouttreatment.D:Isee.Letmetakesomeexamination…OK.IthinkIcanmakeadiagnosisthatshehasgothand,footandmouthdisease.P:Howcanshesufferthisdisease?家長(zhǎng)：沒有。醫(yī)生：她的胃口怎么樣？睡得好嗎？家長(zhǎng)：她的胃口變差了，只吃平時(shí)的一半。昨天晚上她睡得不好。醫(yī)生：她最近有接觸過出現(xiàn)類似癥狀的孩子嗎？家長(zhǎng)：她幼兒園班上的幾個(gè)同學(xué)也有類似的癥狀，我女兒和他們一起玩過。但是他們?cè)跊]有接受治療的情況下痊愈了。醫(yī)生：我明白了。讓我檢查一下吧……現(xiàn)在我可以確診她患的是手足口病。

家長(zhǎng)：她怎么會(huì)得手足口病呢？Conversation2Hand,FootandMouthDisease

手足口病D:It’sakindofcontagiousdiseasethatmainlyhappensinchildren.Itiscausedbysomevirusandcanbetransmittedfrompersontopersonbysalivaordirectcontact.Generallyspeaking,mostofthepatientshaveagoodprognosis.Butfewofthemmaydevelopsomeseverecomplicationssuchasdamageinthebrain,lungorevenheart.Andtheseareusuallyfatal.P:WhatamIsupposedtodo?D:Accordingtomyexperience,yourbaby’ssituationisnotserious,fornosignsofcomplicationshaveappearedyet.Sheneedsnospecialtreatment.Butyoumustkeepherawayfromotherkidsuntiltherashesdisappear.Ithinkitwilltake3—5days.P:Thankyousomuch,doctor.D:That’sallright.Remembertoletherhaveagoodrest.醫(yī)生：這是一種傳染性疾病，主要發(fā)生在小孩身上。它是由一些病毒引起的，主要通過唾液及直接接觸傳染。一般來說，大部分患者預(yù)后良好。少數(shù)會(huì)出現(xiàn)腦部、肺部甚至心臟并發(fā)癥，這些并發(fā)癥往往是致命的。家長(zhǎng)：那我該怎么做呢？醫(yī)生：根據(jù)我的經(jīng)驗(yàn)判斷，你孩子的情況并不嚴(yán)重，不需要特殊治療，因?yàn)闆]有產(chǎn)生并發(fā)癥的跡象。但在她身上的皮疹消失前，你必須讓她和別的孩子隔離開，大概需要3～5天的時(shí)間。家長(zhǎng)：非常感謝您，大夫。醫(yī)生：不客氣。記住要讓她好好休息。Conversation3ChildPneumonia兒童肺炎P:Mychildhashadafeverandcoughedforfourdays.Andtheconditionwasgettingworseyesterday.D:Doesshehaveanydifficultyinbreathingorcomplaintsofchestpains?P:She’sweakandcan’tbreatheeasily.D:I’llexamineherlungs…Mostlikely,it’spneumonia.BringhertotakeachestX-ray.Andcomebacktomewiththeresult.(aftertheexamination)D:Yes,shehaspneumonia.P:Isitserious?Isthereanydangerofthiskindofdisease?D:Don’tworry.Mostchildrenmakeacompleterecoveryfrompneumonia.AndIthinksheshouldbeadmittedtohospitalfortreatment.家長(zhǎng)：我家孩子發(fā)燒咳嗽四天了。昨天起情況加重了。醫(yī)生：她呼吸困難嗎？胸痛嗎？家長(zhǎng)：她軟弱無力，呼吸困難。醫(yī)生：讓我檢查一下她的肺部。很可能是肺炎。帶她去做一個(gè)胸部X光檢查，帶著結(jié)果回來找我。（檢查后）醫(yī)生：不錯(cuò)，她得了肺炎。家長(zhǎng)：病情重嗎？有危險(xiǎn)嗎？醫(yī)生：別擔(dān)心，大多數(shù)得肺炎的孩子都能完全康復(fù)。我建議她住院治療。Conversation3ChildPneumonia兒童肺炎P:Oh,Ihaveanotherchildathometotakecareof.Isitpossibletohavehertreatedintheoutpatientclinic?D:Yes,Iwouldliketogiveherpenicillininjectionstwiceadayfortwodays.Issheallergictopenicillin?P:No.HowshouldItakecareofherathome?D:First,sheneedstogetplentyofrestanddrinklotsoffluidstorecoverfrompneumonia.Second,ahumidifierwillhelpmoistentheairandmayhelpyourchildbreathebetter.Lastbutnotleast,itiswisetokeepyourchildwithpneumoniaawayfromotherchildren,toavoidthespreadofdisease.家長(zhǎng)：家里還有別的孩子需要我照顧，這孩子就在門診治療行嗎？醫(yī)生：可以。我要給她注射青霉素一天兩次，共兩天。她對(duì)青霉素過敏嗎？家長(zhǎng)：不過敏。我在家應(yīng)該怎樣照顧她呢？醫(yī)生：第一，她需要多休息、多喝水。第二，在房間里使用加濕器可以幫助她更好地呼吸。最后但同樣重要的是，讓患肺炎的孩子遠(yuǎn)離其他孩子，以控制疾病的傳播。

Conversation3ChildPneumonia兒童肺炎P:OK,anythingelse?D:Don’tforgettocomebacktotheclinicforherinjectionstwiceaday.Ifherconditiongetsworse,bringherbackanytime.P:Allright,thankyou,doctor.Iwillfollowyouradvice.家長(zhǎng)：還有其他需要注意的嗎？醫(yī)生：別忘了每天到門診來注射兩次藥。如果孩子病情惡化，隨時(shí)帶她來就診。家長(zhǎng)：好的，謝謝您，大夫。我一定會(huì)聽從您的醫(yī)囑。Conversation4Diarrhea腹瀉D:Goodmorning!Haveaseat,please.What’swrongwithyourdaughter?P:Mydaughterissufferingfromdiarrheaaftereatingspoiledformula.D:Whendiditstart?Howfrequently?P:Itstartedtwodaysago.Shegoestothetoilet8to10timesaday.D:Whatkindofstooldidyounotice,wateryormucous?P:Yellowish-greenwaterystools.D:Isshelosingweight?P:No,theweightdidnotchangesignificantly.D:Hasshetakenanymedicine?醫(yī)生：早上好！請(qǐng)坐。你女兒哪里不舒服？家長(zhǎng)：我家女兒食用了變質(zhì)奶粉后開始腹瀉。醫(yī)生：是從什么時(shí)候開始的？一天拉幾次？家長(zhǎng)：兩天前開始的，一天8～10次。醫(yī)生：大便是什么樣的？水樣便還是黏液樣便？家長(zhǎng)：黃綠色稀水便。醫(yī)生：體重下降了嗎？家長(zhǎng)：沒有，體重沒有明顯變化。醫(yī)生：吃藥了嗎？Conversation4Diarrhea腹瀉P:Notyet.D:Doesshehaveanyotherproblems?P:Halfadaybefore,shegotafever.Thehighestbodytemperatureis38.5℃.D:Whataboutherparturition,naturalorcesarean?P:Cesarean.D:Hasshesufferedfromotherdiseasesbefore?P:Sheishealthyandhasneverbeenill.D:Forthree-month-oldbaby’sgastrointestinaltractisnotfullydeveloped,shewasprobablysufferingfrominfantileenteritiscausedbythespoiledformula.Sheneededtobehospitalizedforafewdaystoregulateherintestinalflora.家長(zhǎng)：還沒有。醫(yī)生：還有其他癥狀嗎？家長(zhǎng)：半天前，她開始發(fā)熱，最高體溫達(dá)38.5℃。醫(yī)生：她的分娩過程呢？順產(chǎn)還是剖宮產(chǎn)？家長(zhǎng)：剖宮產(chǎn)。醫(yī)生：她以前得過別的病嗎？家長(zhǎng)：她平常很健康，沒得過病。醫(yī)生：3個(gè)月嬰兒的胃腸道發(fā)育尚未成熟，她大概是由于食用變質(zhì)奶粉而引起了小兒腸炎。她需住院幾天調(diào)節(jié)腸道群菌。

Conversation4Diarrhea腹瀉P:Isthediseaseserious,doctor?D:Notsoserious.Withpropertreatment,shewillgetbettergradually.P:Whatabigrelief!Thankyouverymuch.家長(zhǎng)：我女兒的病嚴(yán)重嗎，醫(yī)生？醫(yī)生：不是特別嚴(yán)重，經(jīng)過適當(dāng)治療她會(huì)逐漸恢復(fù)的。家長(zhǎng)：這樣我總算放心了！謝謝您了，醫(yī)生。課堂小結(jié)這小結(jié)我們學(xué)習(xí)了如何用英語進(jìn)行醫(yī)患交流。希望大家課下多加復(fù)習(xí)，加深對(duì)英語的靈活應(yīng)用。03病歷閱讀OutpatientMedicalRecords—NeonatalJaundiceAdmissionMedicalRecords—PneumoniaPhysicalExamination—InfantilePneumoniaChiefComplaint:Thepatienthadxanthochromiafor20daysandseveralhours.HistoryofPresentIllness:Thepatienthadjaundicethreedaysafterbirth.Thejaundicereachedpeakvalueonthesixthdayandwasreducedafterwards,butthereductionwasslowandthejaundicedidnotcompletelydisappearuntilnow.PastMedicalHistory:Thepatient’smotherwashealthyduringpregnancy,withoutcontacthistoryofacuteandchronicinfectiousdiseasessuchastuberculosisetc.PersonalHistory:Thepatient’smotherstartedexclusivebreastfeedingwithin30minafterdeliveryaccordingtothepatient’sdemand.Thepatienthadthefirstdefecation1hourafterbirth,andhadbeeninoculatedwithBCGvaccineandhepatitisBvaccine.Thepatientwasthesecondchildandwasdeliveredthroughnaturallaborin39+3-weekpregnancy.OutpatientMedicalRecords—NeonatalJaundicePhysicalExamination:T37.8℃;P130bpm;R40times/min;Wt4.1kg;height52cm;headcircumference37cm.Thepatientwasconsciouswithsensitivereactionforflippingofpelma.Thepatienthadnormalappearanceofthenewborn,withflushingcomplexion,stablerespirationandloudcrying.AuxiliaryExamination:Bilirubin23mg/dLPrimaryDiagnosis:PhysiologicjaundiceTreatment:1.OrallytakeYinzhihuangoralliquidandmedilac-vita;takereexaminationafteronecourse.2.Sticktobreastfeeding;feedsomewaterproperly.Doctor’sSignature:Liu××OutpatientMedicalRecords—NeonatalJaundiceOutpatientMedicalRecords—NeonatalJaundice門診病歷—新生兒黃疸主訴：皮膚黃染20余天。現(xiàn)病史：出生后第三日出現(xiàn)黃疸，第六日達(dá)到峰值，后黃疸有所下降，但下降緩慢，至今未完全退卻。既往史：母孕期體健，無結(jié)核等急、慢性傳染病接觸史。個(gè)人史：出生后30分鐘內(nèi)開始喂奶。純母乳喂養(yǎng)。按需喂養(yǎng)。生后1小時(shí)第一次排便?？ń槊?、乙肝疫苗已接種?；純合档诙?，孕39+3周順產(chǎn)。體格檢查：T37.8℃，P130次/分，R40次/分，Wt4.1kg，身長(zhǎng)52cm，頭圍37cm。神志清，彈足底反應(yīng)靈敏，正常新生兒外貌，面色紅潤(rùn)，呼吸平穩(wěn)，哭聲響亮。輔助檢查：膽紅素23mg/dL。初步診斷：生理性黃疸處理：1．口服茵梔黃口服液和媽咪愛，一療程后復(fù)查。2．堅(jiān)持母乳喂養(yǎng)，可適當(dāng)喂水。醫(yī)師簽名：劉××Name:Zhu×× Gender:MaleAge:3yearsold Race:HanOccupation:Other MaritalStatus:UnmarriedNationality:China NativePlace:××PresentAddress:×××× RepresentorofMedicalHistory:Patient’smotherDateofAdmission:2ndJul.,2019 Dateofrecord:10:36,2ndJul.,2019ChiefComplaint:Thepatienthadcoughsandexpectorationaccompaniedwithtightnessinbreathingfor1weekandseveraldays.HistoryofPresentIllness:(Narratedbythepatient’smother)Thepatienthadcoughsandexpectorationaftergettingacold1weekago.AdmissionMedicalRecords—PneumoniaThecoughswerecontinuous,itwasdifficulttobeexpectoratesputum,accompaniedwithtightnessinbreathing,sneezing,nasalobstructionandrunningnose,withoutfever,vomiting,convulsion,coma,afternoonhecticfever,nightsweat,cyanosis,stomachacheanddiarrheaetc.Thepatientwasevertreatedinalocalprivateclinic,withunknownspecificmedication,andtheeffectwasnotgood.Thecoughs,expectorationandtightnessinbreathingwereevidentlyaggravated.Forfurthertreatment,theyvisitedclinicofourhospital,andthepatientwasadmittedintoourdepartmentas“neonatalpneumonia”.Sincetheonset,thepatient’sspirit,appetiteandsleepwerepoor,withbasicallynormalstoolandurination.PastMedicalHistory:Thepatientwashealthypreviously,anddeniedmedicalhistoryofacuteandchronicinfectiousdiseasessuchaschickenpox,tuberculosisandmeaslesetc.AdmissionMedicalRecords—PneumoniaThehistoriesofseveretrauma,operation,transfusionandfoodanddrugallergyweredenied.Prophylacticvaccinationwasperformedasscheduled.Complementaryfoodwasprovidedatpropertime.Thepatientwasabletoraisetheheadin2months,turnoverin4months,sitindependentlyin7months,crawlin8monthsandwalkinoneyear.Thegrowthanddevelopmentwerenormal.FamilyHistory:Thepatient’sparentswerehealthywithoutconsanguineousmarriage.Therewasnosimilardiseaseinthefamily,andfamilygeneticdiseasewasdenied.Doctor’sSignature:Zhu××AdmissionMedicalRecords—PneumoniaAdmissionMedicalRecords—Pneumonia入院病歷（病史采集）—肺炎姓名：朱×× 性別：男年齡：3歲 民族：漢職業(yè)：其他 婚姻狀況：未婚國(guó)籍：中國(guó) 籍貫：××現(xiàn)住址：×××× 病史陳述者：患者母親入院日期：2019-07-02 病歷記錄時(shí)間：2019-07-02，10:36主訴：咳嗽、咳痰伴氣緊1+周。AdmissionMedicalRecords—Pneumonia入院病歷（病史采集）—肺炎現(xiàn)病史：（患兒母親代述）患兒于1周前受涼后開始出現(xiàn)咳嗽、咳痰，呈連續(xù)性咳嗽，有痰難咳出，伴氣緊、打噴嚏、鼻塞、流涕。無發(fā)熱、嘔吐、抽搐、昏迷，無午后潮熱、盜汗、發(fā)紺，亦無腹痛、腹瀉等癥狀。曾在當(dāng)?shù)厮饺嗽\所治療，具體用藥不詳，效果不理想。且咳嗽、咳痰、氣緊明顯加重，為求進(jìn)一步治療而于今日來我院門診就診，擬診“新生兒肺炎”收入我科住院治療。病后患兒精神、食欲、睡眠差，大、小便基本正常。既往史：平素體健，否認(rèn)水痘、結(jié)核、麻疹等急、慢性傳染病史，否認(rèn)重大外傷及手術(shù)史，無輸血史，否認(rèn)食物及藥物過敏史，按計(jì)劃預(yù)防接種。適時(shí)添加各種輔食，二個(gè)月會(huì)抬頭，四個(gè)月會(huì)翻身，七個(gè)月能獨(dú)坐，八個(gè)月會(huì)爬，一歲會(huì)走路，生長(zhǎng)發(fā)育如同齡兒。家族史：父母體健，非近親婚配。家庭中無類似疾病，否認(rèn)家族遺傳性疾病。醫(yī)生簽名：朱××Temperature:37.6℃ Pulse:142bpmRespiratoryRate:68bpm BloodPressure:74/48mmHg Weight:8,100gThepatient’sgrowthwasnormal,withmoderatenutrition.Thepatientwasconsciouswithapoorspirit,acutecomplexion,appearanceofwheezeandactiveposition,andwasnotcooperativeforexamination.Noyellowstaining,hemorrhagicspotandrashwerefoundonskinandmucosaalloverthebody.Theskinwaselasticwithoutedema.Noenlargementofsystemicsuperficiallymphnodeswasfound.Nodeformationofskullwasfound.Thebregmawasclosed,withoutpressurealopecia.Noedemaofeyelids,hyperemiaandedemaofconjunctiva,andyellowstainingofsclerawasfound.Thecorneawastransparent.Eyemovementswerefree.Bilateralpupilswereequalandround,withadiameterof3mm,andwerereactivetolight.……詳見課本第82頁P(yáng)hysicalExamination—InfantilePneumoniaPhysicalExamination—Infanti