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病历摘要女婴,4个月。因发热、腹泻粘液脓性便4天,于1981年5月27日上午8时30分入院。患儿4日前始低热,呕吐胃内容物,一日2次;腹泻每日3～4次,泻物初为水样,以后呈粘液脓性便。人院前1日高热,体温40℃左右,腹泻频繁,每日10余次。基层医生曾用庆大霉素等治疗,腹泻无好转,遂转来我院。患儿系统一胎,足月顺产,母乳喂养,未加辅食。既往无高热、惊厥、外伤史。近期患儿所在的托儿所有菌痢患者,余无其他传染病接触史。否认癫痫等家族史。体检:体温38.4℃,脉搏160次/分,呼吸40次/分。发育正常,营养差,急性病容,来见明显脱水征。巩膜无黄染,未见皮疹。全身浅表淋巴结不大。头颅无异常,颈项软。
Medical summary Baby girl, 4 months. Due to fever, diarrhea, mucopurulent it for 4 days, at 8:30 on May 27, 1981 was admitted. Children 4 days ago, low heat, vomiting stomach contents, 2 times a day; diarrhea 3 to 4 times daily, diarrhea early for the water samples, then mucoid purulent. People on the 1st hospital fever, body temperature about 40 ℃, frequent diarrhea, more than 10 times daily. Primary doctors have used gentamicin and other treatment, no improvement in diarrhea, then transferred to our hospital. A child with a child system, term full-term, breastfeeding, without complementary food. No previous high fever, convulsions, history of trauma. Recent children with nursery bacillary dysentery where there is no other contact history of infectious diseases. Denied family history of epilepsy. Physical examination: body temperature 38.4 ℃, pulse 160 beats / min, breathing 40 beats / min. Normal development, poor nutrition, acute illness, see obvious signs of dehydration. Sclera no yellow dye, no rash. Systemic superficial lymph nodes is not large. No abnormal skull, soft neck.