Admission
The People¡¯s Hospital of Xuchang of Henan Province
Hospitalization card
Admission number: xxx
Medical insurance number:
Name: Xxx Gender: Female Age:16
Place of origin: Xuchang Address: Xuji Garden, Weidu area, Xuchang
Admission method: Self walking¡Ì Support Stretcher
Clinic diagnosis: 1. Viral myocarditis 2. Upper respiratory tract infection
Intended to live in departments or wards: Pediatrics
Disease summary and precautions:
Admission
Department: Pediatrics Doctor: Xxx
Admission date: Aug 10, 2016
The People¡¯s Hospital of Xuchang
Diagnosis Certificate
Outpatient number:
Admission number: 359286
Medical insurance number:
Name: Xxx Age:16 Gender: Female Department: Pediatrics
Diagnostic opinions: 1. Viral myocarditis 2. Upper respiratory tract infection
Treatment course and opinion: Admission with examination. Treatment with myocardial nutrition, and anti-inflammatory and antiviral drugs. The symptoms were relieved. Allow to discharge. Doctor¡¯s suggestion: rest and review after 2 weeks.
Doctor: xxx
Aug 25, 2016
Seal: The People¡¯s Hospital of Xuchang
Medical special Stamp
No seal is invalid
The People¡¯s Hospital of Xuchang
Discharge Certificate
Name: Xxx Gender: Female Age:16 Admission number: 359286
Place of origin: Xuchang Address: Xuji Garden, Weidu area, Xuchang
Admission date: Aug 10, 2016 Discharge date: Aug 25, 2016
Discharge diagnosis: 1. Viral myocarditis
2. Upper respiratory tract infection
Discharge suggestion: Rest
Department: Doctor: xxx Li
Stamp: Aug 25, 2016
Seal: The People¡¯s Hospital of Xuchang
Medical special Stamp
Name: Xxx Gender: Female Age: 16 Bed number: 17 Admission number 359286
The People¡¯s Hospital of Xuchang
Admission record
Department: Pediatrics Bed number: 17 Admission number: 359286
Admission record(first) History of allergy: none
Name: Xxx Gender: Female Age: 16 Place of birth: Xuchang
Occupation: others Marital status: unmarried Nation: Han Admission date: Aug 10, 2016 08:57
ID number: xxx Admission situation: ¡ñcommon ¡ðemergency ¡ðcritical
Tel: xxx Record date: Aug 10, 2016 18:54
Current address: Xuji Garden, Xuchang Work unit: none
Contact name: xxx Relationship with patient: Father History statement: Children¡¯s father
Contact address: Xuji Garden, Xuchang Tel: xxx Reliability: reliable
Chief complaint: chest tightness for 2 days
History of present illness: The patient was chest tightness for 2 days without obvious inducement. The patient occasionally had a cough, coughed with phlegm. There was occasionally a sigh, shortness of breath. No perioral cyanosis, dyspnea, vomit, diarrhea, fever, nor twitch. The patient was admitted in The People¡¯s Hospital of Xuchang yesterday and took examination of routine blood test, throat swab, electrocardiogram, and chest radiograph. No treatment was taken later. The symptoms did not relieve. The patient was treated in our hospital. The patient was admitted due to viral myocarditis. Less diet. Stool and urine was normal. Poor sleep and spirit.
Past history
The patient was health. The patient was admitted due to pneumonia and amygdalitis several times (the concrete was unknown). No operation, history of trauma and blood transfusion. No hepatitis or tuberculosis contact history of infectious diseases. No history of drug and food allergies. The preventive vaccination was taken with local.
Personal history
First child. The child was born after the normal period of gestation via cesarean section. No history of asphyxia. Artificial feeding. Add the food supplement at the right time. Weaning at the age of 1. Rising at 2 months. Sitting at 6 months. Walking at the age of 1. The mental and physical development was consistent with normal children of the same age.
Family history
No family history. The parents and a younger sister are healthy.
The above information was provided by the patient. Patient/family members signature:
Physical examination
T 36.6¡æ P86 times/min R 25 times/min W 51kg
Normal development, medium nutrition, clear consciousness, acute tolerance. The skin color was normal. No cyanosis or yellow dye. Warm skin, normal elasticity. No edema, rash or bleeding point. No enlarged lymph nodes were touched. No malformation of the head, normal distribution of hair. fontanel closed. No special face. There was no swelling and sagging of the eyelids. There was no congestion in the conjunctiva. The pupils were the same size. The light reflex was normal. The ear was no malformation without local swelling. The appearance of nasal was normal. Nasal flap and secretions. There was no pain in the sinuses. No mouth breathing, the lip was no cyanosis. The oral mucosa was smooth without ulcer. Pharyngeal congestion, bilateral enlargement of the amygdala I. The neck was symmetrical without jugular vein. The neck was without resistance. Thyromegaly, the trachea was in the middle without deformity. Bilateral respiratory motion was symmetrical without dyspnea. Breathing 25 times/min. Two lungs¡¯ breathing sounded rough, and no moist rales nor pleural friction sound. No uplift in the cardiac anterior region, no tremor, little heart, low heart sound, heart rate 86 times/min. The rhythm of the heart was regular. No noise in the auscultation area of each valve. There was no swelling in the abdomen. No varicose veins, no gastrointestinal type nor creeping wave. Flat and soft, without tenderness. No lump was touched. No touch the subcostal liver and spleen. No percussion pain in the double kidney area, no shifting dullness sounds. Bowel sounded normal. There was physiological curvature of the spine. Free movement of limbs. No deformity nor varicose veins of lower extremity. No edema in double lower limbs. Perineum, anus, and external genital organs were normal. The Dural irritation sign was negative, and the bilateral syndrome was negative.
Supplementary examination
Aug 9, 2016, The People¡¯s Hospital of Xuchang, routine blood test: white blood cell 9.57 x 10^9/L, red blood cell 4.79 x 10^12/L, hemoglobin 137 g/L, platelet 197 x 10^9/L, percentage of neutrophils 53.60%, lymphocyte percentage 39.5%, throat swab examination for mycoplasma was positive. No bacteria, Borrelia vincenti, B.vincentii, inclusion body of chlamydia were founded. Electrocardiogram: sinus rhythm, myocardial ischemia in the ST-T area. Chest radiograph: cardiac and pulmonary septum was not obviously abnormal.
Preliminary diagnosis:
1. Viral myocarditis
2. Respiratory tract infection
Admission doctor:xx Signature
Section officer: Signature
Seal: The People¡¯s Hospital of Xuchang
File copy dedicated seal.
