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叶××,男,2天,住院号43,271。于1981年10月17日入院。患婴,第2孕第2胎,足月顺产,出生体重3kg。出生时轻度窒息,经注射可拉明0.5ml后自然啼哭。拒奶,口吐白泡沫,发热,打喷嚏,哭声细,但无气促、发绀及呕吐。体检:T37.8℃,心率156次,呼吸70次。神清,双眼距较窄,发育、营养一般,哭声细,反应尚可,唇及皮肤淡红色,无发绀、黄疸。无明显的三凹征,呼吸较促,左头顶有1个3×3cm血肿,前囱3×2cm,平坦,骨缝无增宽、胸廓无畸形;心率156次,律整,心音有力,未闻杂音;双肺底可闻小水泡音及少许干啰音?谷?肝于右肋下3cm、质软,脾未触及。双下肢明显凹陷性水肿。肛门外生殖器无畸形,阴囊浮肿。拥抱、吸吮反射存在。实验室检查:10月18日:Hb12.5g%,RBC335万,WBC9,000,N75%,L25%;尿常规:WBC4～8,蛋白+;10月20日:血清直接胆红素2mg%,间接胆红素9.25mg%。血培养无菌生长。10月22日血气分析:PH7.324,PCO_255.1%,PO_2139.4%,BE+0.5,HCO~-27.4,CO_2CT29.1;10月21日全胸片:右侧中下肺野可见斑片状模糊影,以中内肺野为著,左侧中下肺野由于被心脏所掩盖显示不清,心影观察不满意。意见:右下肺炎。
Leaf × ×, male, 2 days, hospital number 43,271. In October 17, 1981 admission. Suffer from infancy, 2nd pregnancy 2nd, full-term birth, birth weight 3kg. Mild suffocation at birth, after injection of 0.5ml Lamin can naturally cry. Refused to milk, vomit white foam, fever, sneezing, crying fine, but no shortness of breath, cyanosis and vomiting. Physical examination: T37.8 ℃, heart rate 156 times, breathing 70 times. God clear, narrow eyes, development, nutrition in general, crying thin, the reaction is acceptable, lips and skin pink, no cyanosis, jaundice. No obvious three concave signs, breathing more promotion, the left head has a 3 × 3cm hematoma, the front chimney 3 × 2cm, flat, no suture no widening, no deformity of the thorax; heart rate 156 times, rhythm, powerful heart sounds, not Smell murmur; double lungs can smell a little blisters sound and a little dry rales? Valley right liver in the ribs 3cm, soft, spleen not touched. Depression of both lower extremity edema. No external genital abnormalities, swelling of the scrotum. Hugging, sucking reflex exists. Laboratory tests: October 18: Hb 12.5g%, RBC 3350, WBC 9000, N 75%, L 25%; Urine routine: WBC 4-8, protein +; October 20: Serum direct bilirubin 2mg% Indirect bilirubin 9.25mg%. Blood culture aseptic growth. October 22 blood gas analysis: PH7.324, PCO_255.1%, PO_2139.4%, BE +0.5, HCO ~ -27.4, CO_2CT29.1; October 21 full chest radiograph: Flaky shadow, in the lung field as the left lung field due to being covered by the heart shows unclear, psychic observation is not satisfied. Opinion: Right lower pneumonia.