Nanjing children’s hospitalMedical Records for AdmissonWard:321 Bed Number:32178 Medical Number: 696235 General informationName:Son of ***Sex: MaleAge: 3 hBirthplace: *** county,Anhui provinceRace:HanAddress:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015Date of record: 3:31pm Oct 16th,2015Parents Name: father *** Mother ***Complainer of history: patient’s fatherReliability: ReliableChief complaint: Shortness of breath and moaning for 3h Present illness:The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.Past historyNo history of any kind of disease.No history of infective diseases. No history of picking front tooth.No history of wiping oral cavity.Personal history1.Natal: second birth born,Gestational age:28 weeks;Multiplets:No;In Vitro fertilization:NoCause of premature birth:unknown;Time of birth:2015-10-16 11:00Mode of delivery:spontaneous delivery,born in local hospital Deliverer:practioner;Apgar scale:1min 7’,5min unknownResuscitation:No;Birth weight:1350gThe characteristics and volume of amniotic fluid remains unknown,as well as whether there was fetal aspiration of amniotic fluid or meconium.we also have no idea if there was Premature rupture of the amniotic fluid.Umbilical cord is normal;Jaundice:unknown2.Nutrition: breast feed has not been initiated.He had no signof defecation or vomit.3.Immunization: B.C.G and hepatitis B vaccine have not beeninoculated after birth;Other vaccination remains unknown. Family historyFather:Name:***;Age:29ys;Vocation:worker;Healthcondition:good;Blood type:ABMother:Name:***;Age:26ys;Vocaton:peasant;Healthcondition:good;Blood type:unknownMother’s history of pregnancies and births:2 pregnancies,no abortion;This pregnancy was normal.Existing siblings: a healthy sister of 2 and half years oldNo history of drug allergy or physical contact with pets;No history of drug abuse or venereal disease.Physical examinationT 34.1℃, P 126/min, R 70/min, BP 54/26mmHg.Weight 1380g. General descriptionHis consciousness is clear;He has Premature appearance,slight cyanosis on the face.He had shortness of breath along with obtuse response and moaning.Skin and mucosaThere is slight cyanosis of the skin.Elasticity is good. No edema.No sign of dehydration.No jaundice.No dermatoma.No bleeding or rash.HeadNo deformities of the Cranium.Anterior fontanelle 2cm*2cm,skin tensity is flat and soft..Hair is black.No hematoma or edema.Seams at the width of 2mm have not been sealed.Eye:Bilateral pupils were round and equal in size about 2mm*2mm. Movement was normal.Direct and indirect pupillary reactions to light were sharp.Conjunctiva was not congestive.No discharges were found around the eyes.Ear:No discharges were found in external auditory canals. No deformity in external auditory canals.Bilateral auricles werewell developed.Nose:No nares flaring. No deformity.Mouth: Oral mucous membrane was intact. No cleft palate. Neck: No resistence during examination. No masses at bilateral sternocleidomastoid muscles.ChestThorax: Symmetric bilaterally.Lungs:Respiratory movement was hyperactive with three concave sign.Breath sound was rough. Moan and goan can be heard as well.Heart:Heart rate 126/min.Heart sounds were strong and no splitting. Cardiac rhythm was regular. No pathological murmurs.Abdomen:Flat and soft. Skin was normal.Gastralintestinal type or peristalses were not seen. No discharges or flare were found in the umbilical area.No umbilical hernnia. Abdominal muscles were soft.Liver was soft.Liver was touched 2cm under the right costal margin but unreachable in subxiphoid regions. Spleen was unreachable under the left costal margin. No masses. Shifting dullness negative. Borborygmus was existent. Spine and Extremities: No deformity. Muscle tensity of all limbs were normal.Extremitis were warm.Capillary filling time was 2s. Neural system: Physiological reflexes were existent without any pathological ones.Anus and External genitalia: External genitalia appeared to be male’s.Anus was existent.No hypospadias.No testes were touched in bilateral scrotum.Specialized InvestigationLaboratory and instrument inspectionBlood sugar(2015-10-16,our hopital):10.8mmol/LClinical Impression:1. ARDS(Acute respiratory dyspnea syndrome) of prematurity2.pneumonia of prematurity3.very low birth weight infantSignature:Diagnosis for admission:1. ARDS(Acute respiratory dyspnea syndrome)of prematurity2.pneumonia of prematurity3.very low birth weight infantSignature:。