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病例摘要 女孩,4岁,甘肃省庆阳县人,于1994年6月9日入院。患儿于半年前无诱因而开始发热,体温在38～40℃之间,呈不规则热型,发热时无皮疹,无寒战。用退热剂有时可奏效。精神稍差,腹胀,纳差,但无恶心呕吐,出汗稍多,消瘦,乏力,偶有咳嗽,无气喘。尿呈淡黄色,大便稍干燥,无关节痛。3个月前曾鼻衄1次,出血数滴,经局部填塞后血止。发病2个月时曾到当地医院就医。诊断为:“肺炎、贫血”,给庆大霉素,红霉素注射、肌注维生素B_(12),并输血400ml,经上述治疗。病情未见减轻,来本院按“慢性充血性脾大”收住。既往体质较差,易“感冒”,否认传染病史。
Case Summary The girl, 4 years old, from Qingyang County, Gansu Province, was admitted on June 9, 1994. Children six months ago, no incentive to start fever, body temperature between 38 ~ 40 ℃, was irregular heat type, fever, no rash, no chills. Antipyretics can sometimes be effective. Poor spirit, bloating, anorexia, but no nausea and vomiting, sweating slightly, weight loss, fatigue, occasional cough, no asthma. Urine was light yellow, stool a little dry, no joint pain. 3 months ago had epistaxis 1 times, a few drops of blood, blood after partial filling only. Two months have been to the local hospital for medical treatment. Diagnosis: “pneumonia, anemia,” to gentamicin, erythromycin injection, intramuscular injection of vitamin B_ (12), and transfusions 400ml, the above treatment. No reduction in illness, to the hospital according to “chronic congestive spleen” admitted. Past physical health is poor, easy to “cold”, denied a history of infectious diseases.