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例1 男,53天。住院号953432。第三胎第三产,足月顺产。出生时一般情况好,生后母乳喂养,吸吮力弱,吃奶量少,平时哭声低,自主活动少。近1周哭无力,吃奶及吞咽困难伴口吐泡沫轻咳就诊。父母身体健康,非近亲婚配,妊娠期间胎动少。体检:T38.7℃.P140次/分,体重3kg,身长51cm。头围39cm,发育营养较差。神清,头面部无畸形,反应可。颈软,前囟2×2.5cm平软,咽红,高腭弓,可见鼻扇三凹征,呼吸急促,两肺满布痰鸣音及细湿罗音,心脏听诊正常。全身肌张力低下,上肢肌力2级,下肢
Example 1 male, 53 days. Hospital number 953432. The third child the third birth, term full-term. Birth is generally good, after birth, breastfeeding, sucking weak, less milk, usually cry low, less active. Crying nearly 1 week, nurse and swallowing difficulties with vomiting bubble cough cough treatment. Parents healthy, non-relatives marriage, fetal movement during pregnancy less. Physical examination: T38.7 ℃ .P140 times / min, weight 3kg, length 51cm. Head circumference 39cm, poor development and nutrition. Clear, no facial deformities, the reaction can be. Soft neck, anterior fontanel 2 × 2.5cm flat soft, red throat, high palatal arch, showing three concave sign of nasal fan, shortness of breath, lungs covered with phlegm sounds and fine wet rales, cardiac auscultation normal. Systemic muscle tone is low, upper limb muscle strength 2, lower limbs