Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the presenting concerns of the parents/guardian regarding the infantile hemangioma. This may include:
Presence of a red birthmark or mark that has grown in size or changed color.
Location of the hemangioma (e.g., face, scalp, limb)
Any concerns about size, color, or bleeding.
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at initial detection of the hemangioma.
Rate of growth (rapid, slow, or stable).
Changes in color (reddening, darkening).
Any history of bleeding from the hemangioma.
Functional concerns related to the location (e.g., vision obstruction if on the eyelid).
既往史 (jì wàng shǐ) Past Medical History:
History of prematurity or low birth weight (may increase risk).
Any other medical conditions in the infant.
Family history of infantile hemangiomas (uncommon).
家族史 (jiā zú shǐ) Family History:
Family history of hemangiomas (uncommon).
社会史 (shè huì shǐ) Social History:
Not typically relevant for infantile hemangiomas.
查体 (chá tǐ) Physical Examination:
General examination: assess overall health and growth.
Dermatologic examination:
Location, size, and color of the hemangioma.
Texture (smooth, lobular)
Temperature (warmth may indicate active growth).
Assess for ulceration or bleeding.
Functional examination:
Assess for any functional impairment due to location (e.g., vision).
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Imaging studies are not routinely needed for diagnosis of typical infantile hemangiomas.
Ultrasound (Doppler) – may be used in specific cases to assess depth and blood flow within the hemangioma.
MRI (rarely needed) – may be used to evaluate complex hemangiomas or those near critical structures.
诊断 (zhěn duàn) Diagnosis:
Infantile hemangioma.
Specify the location of the hemangioma.
Consider adding descriptors if present (e.g., rapidly involuting hemangioma, ulcerated hemangioma).
分期 (fēn qī) Classification (optional):
Some classification systems categorize infantile hemangiomas based on growth phases (proliferative, involuting).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Most infantile hemangiomas follow a natural course of growth and involution, requiring only observation.
Discuss the reassurance and watchful waiting approach with the parents/guardian.
Consideration for intervention may be needed in specific cases, such as:
Hemangiomas with rapid growth or causing functional impairment.
Hemangiomas located near critical structures (e.g., eye).
Ulcerated hemangiomas at risk of bleeding or infection.
Treatment options (if intervention is needed):
Topical corticosteroids (may be used for small, superficial hemangiomas).
Oral corticosteroids (reserved for more severe cases).
Beta-blockers (propranolol) – a newer medication showing promising results.
Vincristine or other medications (rarely used).
预后 (yù hòu) Prognosis:
Reassure parents/guardian that most infantile hemangiomas eventually involute without treatment.
Discuss the expected timeline for growth and involution (typically involutes by age 5-7 years).
Explain potential complications associated with specific hemangioma locations.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of avoiding trauma to the hemangioma.
Sun protection for exposed hemangiomas.
Reassurance that the hemangioma will likely resolve on its own.
Signs and symptoms to watch for that may necessitate a return visit (e.g., rapid growth, bleeding, ulceration).
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for follow-up appointments to monitor the hemangioma and address any concerns.
Frequency of follow-up depends on the severity and growth pattern of the hemangioma