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叶某某之子,男,2天。入院时间:1981年10月17日住院号:43271 患婴,第二孕第二胎,足月顺产,出生体重3公斤。出生时轻度窒息,经住射可拉明1/3支后自然啼哭。拒奶,口吐白沫,发热,打喷嚏,哭声细。但无气促、发绀、呕吐。入院时体检:37.8℃,脉搏156次/分,呼吸70次/分。神清,双眼距较窄,发育、营养一般,哭声细,反应尚可,唇及皮肤无发绀、黄疸,淡红色。无明显的三凹征,呼吸促,左头顶有一个3×3厘米血肿,前囟3×2厘米,平坦,骨缝无增宽。胸廓无畸形。心率156次/分,律整,心音有力,未闻杂音,双肺底可闻小水泡音及少许干罗音。腹软,
Ye Moumou son, male, 2 days. Admission date: October 17, 1981 Hospital number: 43271 Infant, the second second pregnancy, full-term birth, birth weight 3 kg. Mild suffocation at birth, by Shoulao 1/3 branch naturally crying. Refused to milk, foaming at the mouth, fever, sneezing, cries. But no shortness of breath, cyanosis, vomiting. Physical examination on admission: 37.8 ℃, pulse 156 beats / min, breathing 70 beats / min. Clear, narrow eyes, development, nutrition in general, crying thin, the reaction is acceptable, no cyanosis of the lips and skin, jaundice, pink. No obvious three concave signs, breathing, the left top of a 3 × 3 cm hematoma, anterior fontanel 3 × 2 cm, flat, no widening of the suture. Thorax without deformity. Heart rate of 156 beats / min, the whole law, powerful heart sounds, no unheard noise, the bottom of the lungs can be heard a small blisters sound and a little dry rales. Abdomen soft,