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海××,男,4天,住院号2810.因哭闹拒乳半天,阵发性青紫一小时,于1982年7月21日上午9时入院.患儿系第一胎,足月顺产,新法接生,生时哭声响亮.检查:体温37.2℃,心率120次/分,营养发育中等,皮肤巩膜轻度黄染,口唇阵发性青紫,张口呼吸,且不规则.口腔及咽部多分泌物,双侧瞳孔如针尖大小.前囟3×3厘米,不饱满.颈软,心律齐无杂音.两肺呼吸音清晰,未闻及干湿性罗音.腹平软,肝右肋缘下3厘米,质软,脾未触及.神经系检查无病理反射.初步印象:新生儿肺炎.入院后经输氧,肌注青霉素及静滴氨苄青霉
Sea × ×, male, 4 days, hospital number 2810. Refused to cry for a long time because of crying, paroxysmal cyanosis for one hour, July 21, 1982 at 9 am admitted to hospital. Children with the first child, term full- New law, birth loud cry .Check: body temperature 37.2 ℃, heart rate 120 beats / min, moderate nutrition development, skin scleral mild yellow dye, paroxysmal purple lips, mouth breathing, and irregular .And oral and pharyngeal Secretions, bilateral pupils, such as the tip size of the anterior fontanel 3 × 3 cm, not full neck soft, heart rhythm without noise, both lungs breath sounds clear, unheard and wet and dry rales. Margin of 3 cm, soft, spleen not touched.Nervous system examination without pathological reflex.A preliminary impression: neonatal pneumonia.Admission after transfusion, intramuscular injection of penicillin and intravenous ampicillin