英文交班

There are 28 patients in NICU, 3 patients were discharged, 1 patient was admitted.

NICU 2, Zhu Lin, a 20 minutes old girl

Diagnosis:1. Preterm infant

2. Low birth weight infant

Chief compaint: born at 33 weeks with grunting and cyanosis for 20 minutes.

HPI(history of present illness): The mother is 31 yo, G3P2, gestational age is 33 weeks and 6 days. The girl was delivered by cesarean section(C/S) for decreased fetal movement. Her birth weight was 2kg, Apgar score were 6-8-9. The baby was grunting and cyanotic after birth.No history of amniotic fluid aspiration, no convulsion. She was transferred to our department.

PE: premature appearance, grungting and cyanosis. The respiratory rate was 60 times per minute. Three concave sign, nasal flaring, nodding breathing.

Treatment:After admission, we gave her oxygen and CPAP to support her respiration. We also kept warm and gave antibiotic, dopamine, cimetidin and rehydration. Last night, Her oxygen satuation stayed above 95%, blood glucose and blood pressure stayed normal. This morning, the baby’vital signs are stable, her respiratory distress get better . There is no grunting and cyanosis. But the patient need to rule out complication of

preterm infant.

NICU 21, the baby of Lina, 5 days old girl

Diagnosis: idiopathic jaundice to be investigation

HPI：The skin is yellow for 2 days. Mother is 32 yo , G1P1 and delivered with C/S at 38 weeks.The pregnancy was uncomplicanted until then. The baby ‘birth weight is 338 kg. The baby developed jaundice at 4 days after birth . Trans cutaneous billirubin was 14.3-16.9-14.2 mg/dl. Her mother ‘ blood type is A+.

PE: vital signs(写出具体值，而不要用normal ) There are moderate to severe jaundice , and some pustular eruption on her face. No pallor. After admission, we gave her phototherapy and rehydration. This morning her jaundice has gone down to 13.3-12.4-10.1mg/dl. (建议交新生儿时，查体要交体重，而且要交变化，例如：weight is 3.0 Kg which is 9% weight loss since birth)

Case 4, Wu ping, a 6 yo boy

Chief compaint: generalized rash for 1 week, abdominal pain , vomiting, diarrhea for 3 days.

HPI: one week ago, some red penpoint rash with itching appeared on the child’ trunk and limbs. The rash didn’t fade with pressure. No cough,

no expectoraion, no fever and no wheezing. The local hospital diagnosis is “ anaphylactoid purpura”. 3 days ago the child developed abdominal pain, vomiting and diarrhea. Bloody stool. Urination is normal, the weight decreased by 2 kg。

PE: the lungs and heart were normal. The rash on limbs an d trunk were red penpoint papule and can not fade with pressure.