Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to infectious mononucleosis (IM). This may include:
Fatigue and malaise (most common)
Fever
Sore throat (often severe)
Swollen lymph nodes (particularly in the neck)
Headache
Muscle aches
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Progression of symptoms (worsening, stable, or improving).
Any recent exposure to individuals with IM (highly contagious through saliva).
Detailed description of sore throat (severity, presence of exudates).
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions (e.g., autoimmune disorders, spleen enlargement).
Prior history of Epstein-Barr virus (EBV) infection (may not cause symptoms).
家族史 (jiā zú shǐ) Family History:
Family history of IM (uncommon).
社会史 (shè huì shǐ) Social History:
Recent close contact with others (increased risk in crowded settings).
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show elevated temperature).
General examination: assess for fatigue, pallor, and signs of dehydration.
Ear, nose, and throat (ENT) examination:
Swollen and erythematous tonsils (classic finding)
Exudates on the tonsils (may be present)
Posterior cervical lymphadenopathy (swollen lymph nodes in the back of the neck)
Spleen palpation (splenomegaly may be present but should not be aggressively palpated).
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC):
Lymphocytosis (increased lymphocytes) – a typical finding in IM.
Atypical lymphocytes (unusual appearance of lymphocytes) – suggestive of IM.
Monospot test (rapid test):
Provides a quick indication of EBV infection (positive test does not confirm IM).
EBV serology (antibodies):
Confirms past or present EBV infection. This test differentiates between acute IM and past exposure.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely needed for diagnosis of IM.
Ultrasound of the spleen (may be used if splenomegaly is suspected).
诊断 (zhěn duàn) Diagnosis:
Infectious mononucleosis (IM) based on clinical presentation and supportive laboratory findings (e.g., atypical lymphocytes on CBC).
分期 (fēn qī) Staging (not applicable):
Infectious mononucleosis does not have stages.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
IM is a self-limited viral infection, and treatment focuses on symptom management.
Supportive measures include:
Rest
Hydration
Over-the-counter pain relievers (acetaminophen, ibuprofen) for fever and sore throat (avoid aspirin due to risk of Reye’s syndrome)
Throat lozenges or gargling with warm salt water for sore throat relief
Antibiotics are not effective against viruses and are not typically used for IM.
预后 (yù hòu) Prognosis:
Reassure the patient that IM usually resolves within 2-4 weeks.
Fatigue may persist for several weeks after other symptoms improve.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of rest and avoiding strenuous activity until fatigue resolves.
Maintaining adequate hydration.
Avoiding aspirin and aspirin-containing products due to the risk of Reye’s syndrome.
Safe practices to prevent spreading the virus (frequent handwashing, avoiding sharing personal items).
Signs and symptoms to watch for that may necessitate a return visit (e.g., worsening sore throat, severe fatigue, abdominal pain).
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule a follow-up appointment in 7-10 days to monitor symptom improvement and potential complications.
Advise the patient to return sooner if symptoms worsen.