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发布者:鑫达医学翻译 发布时间:2013-02-03 8:50:52 阅读:

Chief complaint: Continuous wheezy phlegm after birth. Severe bucking was observed when sucking.
Medical history: The baby suffered continuous wheezy phlegm in the larynx. Additionally, in the recent one week, aggravated bucking was noted when bucking accompanied with discontinuous short breath. No cyanosis, fever, cough, nasal discharge or obvious frothy salivation was noted. The patient was fed with breast milk with small amount and a high frequency. The urination and defecation was normal.
Physical check: The patient was conscious with normal responsiveness. Tachypnea (about 50-60 times per minute) accompanied with discontinuous mild three concave sign was noted. The skin was mildly yellow. TCB was in a range of 5.6-5.0 mg/dl. The anterior fontanelle was soft and flat. Additionally, the breath sounds of both lungs were coarse. Wheezy phlegm was identified in the larynx. The cardiac rhythm was regular. The heart sounds were powerful. No pathological murmurs were identified. The abdomen was soft with no mass was palpated. Bowel sounds were available. She could move her limbs moved freely. Yellow secretion was observed in the right eye.
Diagnosis:   
1. Bronchopneumonia?  
2. Congenital abnormal laryngeal cartilage formation?
3. Conjunctivitis

Medical order: Complete plain chest radiography and laryngofiberscopy is recommended, but the family gives no consent. The family gives no consent to use antibiotics. More sunshine is suggested. It is recommended to feed the baby carefully, avoid bucking and asphyxia, pay attention to observation on the breath conditions, and visit the clinics in presence of discomforts.
 


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