※ [本文轉錄自某隱形看板]
作者: charater ((￣y▽￣)σ推廣會會長) 看板: (某隱形看板)
標題: Re: [課業] EF組現在run NOR的同學看過來～
時間: Wed May 5 20:40:34 2010
明天有摸咪
討論的case如下: 有興趣的同學可以準備一下
Dx:
1. Hemangioma
2. Generalized petechiea, suspected congenital infection
3. Suspected meconium aspiration syndrome
<Birth history>
1. Birth history: G1P1, GA:37+2 wks, BBW: 2344gm,
NSD, perinatal insult (-),
2. Vaccination: BCG (+), HBV(-)
3. Growth and development:
BBW: 2344 gm ( th percentile)
BL: 44 cm ( th percentile)
HG: 31 cm (75-90th percentile)
4. Feeding: HM/IF q3h as tolerate
5. Maternal history:
(1) Prenatal exam : no abnormally
(2) Radiation exposure during pregnancy: denied
(3) Maternal systemic disease: Denied infection or drug use during pregnancy.
(4) HbsAg (-); HbeAg: (-)
(5) Maternal vaginal GBS colonization(+)during prenatal examination
6. New born screen: pending
<Present Illness>
The just born boy was born to a G1P1, GA37+2 weeks with BBW 2234gm via
NSD. The Apgar score was 7-9. The perinatla course was smooth and he ahd
spontaneous crying. After birth, meconium stain 2+ was noted. Generalized
petechiea over face, trunk and back was noted. There were also generalized
ecchymosis over back and hemangioma over forehead. The prenatal examination
was normal. Under the impression of r/o meconium aspiration and generalized
petechiea, he was admitted ti NOR for further care.
BH: cm BW:2.344 kg
General appearance: fair Activity: well
HEENT: grossly normal, AF: 2x2fb, soft, no bulging, molding(-), No
cephalohematoma
conjunctiva: not pale; sclera: icteric; pupil: isocoric
Neck: supple
Chest: symmetric expansion, breathing sound: bilateral clear
Heart: regular heart beat. Murmur(-)
Abdomen: soft and flat, no tenderness, Liver, spleen: impalpable, Bowel
sound: normoactive
Back: no sacral dimpling
Extremities: freely movable, no petechiae, no skin rash, no edema
Skin: petechiea over face and trunk, ecchymosis over back
Reflex: Moro(+) , Grasp(+), Sucking (+)
趨勢圖 項目 數值 單位 標準值 說明 ViewCond.
RBC 3.47 M/μL ♂: 5.2 ± 1.0 , ♀: 4.6 ± 0.9
HB 11.5 g/dL ♂: 15.3 ± 3 , ♀: 13.3 ± 2
HCT 37.4 % ♂: 46 ± 7 , ♀: 40 ± 7
MCV 107.8 fL 89 ± 10
MCH 33.1 pg 30 ± 4
MCHC 30.7 g/dL 33 ± 3
PLT 61.0 K/μL 220 ± 100
PS
WBC 17.76 K/μL 7.5 ± 3.5
RL BLOOD No:1002780 ( 99.05.05 14:00登記) (99.05.05 14:26報告)
趨勢圖 項目 數值 單位 標準值 說明 ViewCond.
T-BIL 5.06 mg/dl 0.2-1.2 L1H1I4
D-BIL 1.83 mg/dl 0.0 ~ 0.4 L1H1I4
AST 52 U/l ♂ < 37, ♀ < 31 L1H1I4
ALT 11 U/l ♂ < 41, ♀ < 31 L1H1I4
Na 144 mmole/l 135 ~ 148 L1H1I4
K 3.0 mmole/l 3.5 ~ 5.3 L1H1I4
Cl 115 mmole/l 98 ~ 108 L1H1I4
Ca 1.41 mmole/l 2.02~ 2.6 L1H1I4
P 3.6 mg/dl 2.5 ~ 4.5 L1H1I4
Mg 0.53 mmole/l 0.7 ~ 1.03 L1H1I4
RL BLOOD No:1011151 ( 99.05.04 16:14登記) (99.05.04 16:30報告)
趨勢圖 項目 數值 單位 標準值 說明 ViewCond.
PT 15.5 sec 8.0-12.2
PT Cont 11.4 sec
PT INR 1.51
PTT 41.3 sec 26.9-36.3
RL BLOOD No:1011147 ( 99.05.04 15:53登記) (99.05.04 16:05報告)
趨勢圖 項目 數值 單位 標準值 說明 ViewCond.
RBC 4.28 M/μL ♂: 5.2 ± 1.0 , ♀: 4.6 ± 0.9
HB 14.4 g/dL ♂: 15.3 ± 3 , ♀: 13.3 ± 2
HCT 47.3 % ♂: 46 ± 7 , ♀: 40 ± 7
MCV 110.5 fL 89 ± 10
MCH 33.6 pg 30 ± 4
MCHC 30.4 g/dL 33 ± 3
PLT 23.0 K/μL 220 ± 100 recheck
PS
WBC 12.94 K/μL 7.5 ± 3.5 corrected data
Blast 0.0 %
Promyl. 0.0 %
Myelo. 0.0
Meta 0.0 %
Band 0.0 % (band+seg) 40 - 75
Seg 25.2 % (band+seg) 40 - 75
Eos. 2.2 % 1 ~ 6
Baso. 9.0 % 0 ~ 1
Mono. 7.2 % 2 ~ 10
Lym. 56.4 % 20 ~ 45
Aty.Lym. 0.0 %
PlasmaCell 0.0 %
Normobl. 53.0 /100WBC
PS 分類異常
RL BLOOD No:1002141 ( 99.05.04 15:52登記) (99.05.04 16:25報告)
趨勢圖 項目 數值 單位 標準值 說明 ViewCond.
C-Reactive Protein 0.02 mg/dl < 0.8 L1H1I2
YM Arterial Blood No:0710004 ( 99.05.04 20:06登記) (99.05.04
20:09報告)
趨勢圖 項目 數值 單位 標準值 說明
pH 7.401 * 7.35~7.45
pCO2 36.1 mmHg 35~45
pO2 84.8 mmHg 83~108
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◆ From: 59.112.121.151