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標(biāo)準(zhǔn)完整5歲的兒科病歷范文兒科病歷范文參考：

Name:張三Gender:MaleAge:5yearsoldDateofBirth:January1,2015Address:123ABCStreet,City,State

ChiefComplaint:

Thepatientpresentswithapersistentcough,runnynose,andfeverforthepastthreedays.

HistoryofPresentIllness:

Thepatient'sparentsreportthatthesymptomsstartedthreedaysagowithamildcoughandrunnynose.Thesymptomshaveprogressivelyworsened,andthepatientnowhasapersistentcoughandhigh-gradefever.Thecoughisdescribedasdryandnon-productive.Thepatient'sappetitehasdecreased,andheappearsfatigued.

PastMedicalHistory:

Thepatienthasnosignificantpastmedicalhistory.Previousimmunizationsareuptodate.

FamilyMedicalHistory:

Therearenoknowngeneticorchronicdiseasesinthefamily.

BirthandDevelopmentHistory:

Thepatientwasbornfull-termvianormalvaginaldelivery.Birthweightwas3.5kg,andtherewerenocomplicationsduringthedelivery.Thepatientmetalldevelopmentalmilestoneswithinthenormalrangesforhisage.

SocialHistory:

Thepatientliveswithhisparentsandanoldersibling.Bothparentsarenon-smokers,andthereisnoknownexposuretoenvironmentalirritantsorallergens.

PhysicalExamination:

Thepatientappearsmoderatelyillbutalertandoriented.Vitalsignsshowatemperatureof39.5°C,heartrateof110bpm,respiratoryrateof22bpm,andbloodpressureof100/70mmHg.Uponinspection,thepatienthasaflushedfaceandmildconjunctivalinjection.Thereisclearrhinorrheaandmildnasalcongestion.Thethroatismildlyerythematous,butnotonsillarenlargementisnoted.Lungsarecleartoauscultationbilaterallywithnoadventitioussounds.Thehearthasaregularrateandrhythmwithnomurmurs.Abdominalexaminationisunremarkable.Thepatienthasnoskinrashorpalpablelymphnodes.Neurologicalexaminationfindingsarewithinnormallimits.

AssessmentandPlan:

Basedonthehistoryandphysicalexaminationfindings,thepatientisdiagnosedwithanupperrespiratorytractinfection(URTI)andviralbronchitis.Theplanincludessupportivecareconsistingofhydration,rest,andantipyretics(acetaminophen)toreducefever.Thepatientshouldbemonitoredcloselyforanysignsofrespiratorydistress.Patienteducationisprovidedtotheparentsregardingproperhandhygiene,symptomaticreliefmeasures,andwhentoseekmedicalattentionifsymptomsworsenorpersistentfeveroccurs.

Follow-up:

Thepatientisadvisedtofollowupintwotothreedaysifthereisnoimprovementorifsymptomsworsen.AnappointmentisscheduledforJanu

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