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病史摘要患儿男性,12天,因黄染加深3天,食欲不振,四肢发凉,反应差2天于1980年11月15日入院。患儿系第一胎第一产,33周早产,顺产,出生体重1,800克,Apgar 评分10分,3天来黄疸渐加深,伴神萎,吃奶差,时有吐奶,不咳,大便正常。入院体验:体温36.6℃,脉搏90次/分,体重1,600克,未成熟儿貌,反应尚可,精神萎软,皮肤黄疸++～+++,前囟1.5×0.5厘米,平,头部器官无异常,心界不大,心音较强,心率120次/分,两肺呼吸音清晰。腹软,肝肋下刚及,四肢肌张力正常,拥抱反射(±)。
Summary of medical history Male patients, 12 days, dark yellow deepen for 3 days, loss of appetite, cold limbs, poor response 2 days in November 15, 1980 admission. The first birth of children with first birth, 33 weeks of premature delivery, birth, birth weight 1,800 grams, Apgar score 10 points, 3 days to jaundice deepened, with wilting, poor feeding, when spit milk, no cough, normal stool . Admission experience: body temperature 36.6 ℃, pulse 90 beats / min, weight 1,600 grams, immature appearance, the reaction is acceptable, the spirit of atrophy, skin jaundice ++ ~ +++, anterior fontanel 1.5 × 0.5 cm, flat, head No abnormal organ, heart is not big heart sound, heart rate 120 beats / min, two lungs breath sounds clear. Abdomen soft, just under the ribs and ribs, limb muscle tone normal, hug reflex (±).