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患儿曲××,男,2.5个月。住院号:85716。因剧烈咳嗽6天,加重伴喘3天入院。患儿系早产一个月婴儿。查体:T37.3,P180。发育营养中等,急重病容。频发阵咳,喘憋。前囟1.5cm×1.5cm,紧张。双眼球时有上窜,鼻翼扇动,口唇轻度发绀。三凹征阳性。双肺可闻及喘鸣及中小水泡音。心界无明显扩大,心率:180次/分,节律规整,无杂音。肝于右肋缘下4.0cm处可触及,质软,光滑。肝颈静脉反流征不明显.其他系统器官未见异常。实验室检查:WBC7.2×10~9,Sg0.49,Ly0.51。
Children with music × ×, male, 2.5 months. Hospital number: 85716. 6 days due to severe cough, aggravated with asthma 3 days admission. Children are premature babies one month. Physical examination: T37.3, P180. Development of moderate nutrition, acute and severe disease. Frequent cough, wheezing. Anterior fontanel 1.5cm × 1.5cm, nervous. Eyes when the channeling, nose flap, lips mild cyanosis. Three concave sign positive. Two lungs can be heard and wheeze and small blisters sound. Heart no significant expansion, heart rate: 180 beats / min, regular rhythm, no noise. The liver is accessible at 4.0 cm below the right costal margin, soft and smooth. No sign of hepatic jugular vein reflux was found. Other systemic organs showed no abnormalities. Laboratory tests: WBC7.2 × 10 ~ 9, Sg0.49, Ly0.51.