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患儿男,5岁,河南夏邑县人,住院号73076。据诉,患儿食大枣和豌豆后开始腹痛,伴呕吐。第3天就诊当地卫生院,经口服土霉素,腹痛未能缓解且逐渐加重,故转我院。门诊拟为消化道穿孔伴腹膜炎于1983年8月24日收住院。查体:T38℃,P130次/分,R30次/分。两肺呼吸音清晰,心律齐,心率130次/分,未闻杂音。肝脾未触及,腹肌紧张,全腹均有压痛,左下腹尤甚。肠鸣音减弱,无明显移动性浊音,腹部透视发现右隔下有线条状游离气带,提示消化道穿孔。血常规检查,RBC428万,WBC11000、N80％、L20％。 入院当日在氯胺酮分离麻醉下,行剖腹探查术。
Children male, 5 years old, Xiayi County, Henan Province, hospital number 73076. According to the complaint, children with jujube and peas began abdominal pain, with vomiting. The first 3 days of visiting the local hospitals, the oral oxytetracycline, abdominal pain did not ease and gradually increased, so turn my hospital. Outpatient department intended for gastrointestinal perforation with peritonitis was admitted to hospital on August 24, 1983. Physical examination: T38 ℃, P130 times / min, R30 times / min. Breath sounds clear two lungs, heart rate Qi, heart rate 130 beats / min, no noise. Liver and spleen did not touch, abdominal muscle tension, all abdominal tenderness, especially the left lower quadrant. Bowel sounds weakened, no significant migratory dullness, abdomen found the next line of right-sided strip of free gas band, suggesting digestive tract perforation. Blood tests, RBC4.28 million, WBC11000, N80%, L20%. On the day of admission under ketamine anesthesia, laparotomy.