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病例摘要 患儿,男,2小时,因呼吸浅促颜面青紫2小时由外院转入。患儿系第4胎第2产,孕32周剖宫产出生,出生体重2000g,早破水3天,无宫内窘迫,羊水少,色清,脐带胎盘无异常。Apgar评分1分钟10分,5分钟9分。父母非近亲婚配,兄9岁,体健。入院查体:体湿37.1℃,心率 146次/分,呼吸78次/分,血压58/32mmHg,体重1950g。早产儿外貌,颜面青紫伴瘀点,呼吸急促浅表,可见轻度鼻扇及三凹征,双肺呼吸运动对称,无叩浊,呼吸音稍粗,无罗音。心腹无异常。四肢肌张力正常,原如反射存在。入院诊断:新生儿吸入性肺炎,RDS?败血症不除外。
Case summary Children, male, 2 hours, due to shortness of breath facial bruising 2 hours transferred from the outer court. Children with the first 4 births of the second child, 32 weeks gestational age cesarean birth, birth weight 2000g, 3 days early rupture of water, no intrauterine distress, oligohydramnios, color clear, umbilical cord placenta was normal. Apgar score 1 minute 10 minutes, 5 minutes 9 minutes. Parents non-relatives marriage, brother 9 years old, physical health. Admission examination: body temperature 37.1 ℃, heart rate 146 beats / min, breathing 78 beats / min, blood pressure 58 / 32mmHg, weight 1950g. Premature children appearance, facial bruising with petechiae, shortness of breath shallow surface, showing mild nasal fan and three concave sign, lungs respiratory movement symmetry, no knock turbidity, breath sounds a little rough, no rales. No abnormal heart. Limb muscle tension normal, as the reflection exists. Admission diagnosis: neonatal aspiration pneumonia, RDS? Sepsis is not excluded.