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Nanjingchildren’shospitalMedicalRecordsforAdmissonWard:321BedNumber:32178MedicalNumber:696235GeneralinformationName:Sonof***Sex:MaleAge:3hBirthplace:***county,AnhuiprovinceRace:HanAddress:***town,***county,AnhuiprovinceDateofadmission:3:31pmOct16th,2015Dateofrecord:3:31pmOct16th,2015ParentsName:father***Mother***Complainerofhistory:patient’sfatherReliability:ReliableChiefcomplaint:Shortnessofbreathandmoaningfor3hPresentillness:Theafflictedbabywasdelivered3hagoandhadinstaneousshortnessofbreathalongwithobtuseresponseandmoaning.Noaspneaorseizureorscreamwereobserved.InlocalHospitalhereceivedtreatmentof“naloxone、mezlocillinandVitK1”,buthissymptomsdidn’tabate.Sotheparentstookhimtoourhospital,hewasadmittedwithadiagnosisof“acuterespiratorydyspneasyndrome”.Breastfeedhasnotbeeninitiated.Hehasnotvomitted,defecatedorurinatedsincehewasborn,.PasthistoryNohistoryofanykindofdisease.Nohistoryofinfectivediseases.Nohistoryofpickingfronttooth.Nohistoryofwipingoralcavity.Personalhistory1.Natal:secondbirthborn,Gestationalage:28weeks;Multiplets:No;InVitrofertilization:NoCauseofprematurebirth:unknown;Timeofbirth:2015-10-1611:00Modeofdelivery:spontaneousdelivery,borninlocalhospitalDeliverer:practioner;Apgarscale:1min7’,5minunknownResuscitation:No;Birthweight:1350gThecharacteristicsandvolumeofamnioticfluidremainsunknown,aswellaswhethertherewasfetalaspirationofamnioticfluidormeconium.wealsohavenoideaiftherewasPrematureruptureoftheamnioticfluid.Umbilicalcordisnormal;Jaundice:unknown2.Nutrition:breastfeedhasnotbeeninitiated.Hehadnosignofdefecationorvomit.3.Immunization:B.C.GandhepatitisBvaccinehavenotbeeninoculatedafterbirth;Othervaccinationremainsunknown.FamilyhistoryFather:Name:***;Age:29ys;Vocation:worker;Healthcondition:good;Bloodtype:ABMother:Name:***;Age:26ys;Vocaton:peasant;Healthcondition:good;Bloodtype:unknownMother’shistoryofpregnanciesandbirths:2pregnancies,noabortion;Thispregnancywasnormal.Existingsiblings:ahealthysisterof2andhalfyearsoldNohistoryofdrugallergyorphysicalcontactwithpets;Nohistoryofdrugabuseorvenerealdisease.PhysicalexaminationT34.1℃,P126/min,R70/min,BP54/26mmHg.Weight1380g.GeneraldescriptionHisconsciousnessisclear;HehasPrematureappearance,slightcyanosisontheface.Hehadshortnessofbreathalongwithobtuseresponseandmoaning.SkinandmucosaThereisslightcyanosisoftheskin.Elasticityisgood.Noedema.Nosignofdehydration.Nojaundice.Nodermatoma.Nobleedingorrash.HeadNodeformitiesoftheCranium.Anteriorfontanelle2cm*2cm,skintensityisflatandsoft..Hairisblack.Nohematomaoredema.Seamsatthewidthof2mmhavenotbeensealed.Eye:Bilateralpupilswereroundandequalinsizeabout2mm*2mm.Movementwasnormal.Directandindirectpupillaryreactionstolightweresharp.Conjunctivawasnotcongestive.Nodischargeswerefoundaroundtheeyes.Ear:Nodischargeswerefoundinexternalauditorycanals.Nodeformityinexternalauditorycanals.Bilateralauricleswerewelldeveloped.Nose:Nonaresflaring.Nodeformity.Mouth:Oralmucousmembranewasintact.Nocleftpalate.Neck:Noresistenceduringexamination.Nomassesatbilateralsternocleidomastoidmuscles.ChestThorax:Symmetricbilaterally.Lungs:Respiratorymovementwashyperactivewiththreeconcavesign.Breathsoundwasrough.Moanandgoancanbeheardaswell.Heart:Heartrate126/min.Heartsoundswerestrongandnosplitting.Cardiacrhythmwasregular.Nopathologicalmurmurs.Abdomen:Flatandsoft.Skinwasnormal.Gastralintestinaltypeorperistalseswerenotseen.Nodischargesorflarewerefoundintheumbilicalarea.Noumbilicalhernnia.Abdominalmusclesweresoft.Liverwassoft.Liverwastouched2cmundertherightcostalmarginbutunreachableinsubxiphoidregions.Spleenwasunreachableundertheleftcostalmargin.Nomasses.Shiftingdullnessnegative.Borborygmuswasexistent.SpineandExtremities:Nodeformity.Muscletensityofalllimbswerenormal.Extremitiswerewarm.Capillaryfillingtimewas2s.Neuralsystem:Physiologicalreflexeswereexistentwithoutanypathologicalones.AnusandExternalgenitalia:Externalgenitaliaappearedtobemale’s.Anuswasexistent.Nohypospadias.Notestesweretouchedinbilateralscrotum.SpecializedInvestigationLaboratoryandinstrumentinspectionBloodsugar(2015-10-16,ourhopital):10.8mmol/LClinicalImpression:1.ARDS(Acuterespiratorydyspneasyndrome)ofprematurity2.pneumoniaofprematurity3.verylowbirthweightinfantSignature:Diagnosisforadmission:1.ARDS(Acuterespiratorydyspneasyndrome)ofprematurity2.pneumoniaofprematurity3.verylowbirthweightinfantSignature: