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第一次查房(11月12日) 实习医师:介绍病历摘要。男婴,37天,。第一胎,足月顺产。出生第二天来,咳嗽、呕吐、间歇呼吸困难、紫绀、颈静脉怒张、无发热,腹泻、间歇期数小时至数天不等,无症状。曾三次住某院,胸片报告“肺膨胀不全”“右下肺炎”“心影增大”经抗菌、强心等治疗,好转出院。近三天以上症状反复出现并加重,伴发热、拒食,1985年11月8日转本院诊治。检查:T38.5℃,P180次/分,R46次/分,发育中等,囟门未闭,无隆起或凹陷,无皮疹、出血点,巩膜无黄染,安静时皮肤红润,间歇烦躁哭闹、鼻翼扇动、口唇紫绀、全身皮肤花纹状。气管居中,颈静脉充盈,两肺呼吸音粗糙,肺底少量细湿罗青,两肩胛下呼吸音低,尤以右侧明显,叩为浊音,心律齐,无杂音,无心音低钝或遥远,心浊音界两侧扩大,右侧为主。腹部稍膨,软,无包块,无腹壁静脉曲张,安静时肝脏肋下0.5cm,呼吸困难时肋下3～5cm,质中等,肝、颈反流阳胜,脾脏未触及,手足温暖,活动自如,无水肿,神经系统检查无异常。
First round of rounds (November 12) Interns: introduction of medical records summary. Baby boy, 37 days. The first child, full-term follow-up. The second day of life, cough, vomiting, intermittent breathing difficulties, cyanosis, jugular vein engorgement, no fever, diarrhea, intermittent period of several hours to several days, asymptomatic. Had three times to live in a hospital, chest radiograph report “pulmonary insufficiency,” “right lower pneumonia,” “heart shadow increased” by antibacterial, cardiac and other treatment, improved discharged. Repeated symptoms and aggravate the symptoms over the past three days, with fever, antifeedant, November 8, 1985 transferred to the hospital for diagnosis and treatment. Check: T38.5 ℃, P180 beats / min, R46 beats / min, medium development, fontanelle closed, no uplift or depression, no rash, bleeding, scleral no yellow dye, quiet skin rosy, intermittent irritability crying, Nose flap, cyanotic lips, body skin pattern. Tracheal center, filling the jugular vein, rough breathing sounds of both lungs, a small amount of lungs at the end of wet Luo Qing, low sound pressure below the two subscapular, especially in the right obvious, knocking voiced, Qi Qi, no noise, no heart sound low blunt or far , Heart dullness on both sides of the expansion, the main right. Abdomen slightly swollen, soft, without mass, no abdominal varicose veins, when the liver ribs ribs 0.5cm, Breathing difficult ribs 3 ~ 5cm, medium quality, liver and neck reflux Yang wins, spleen not touched, warm hands and feet, Free activity, no edema, nervous system examination without exception.