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男孩,1岁1个月,于1994年8月18日入院。患儿于3日前出现惊厥,发作时右侧肢体抽动,口角右斜,双眼凝视,神志模糊,持续1小时用药后缓解,2日来发作多次,无发热、呕吐及腹泻,缓解后一切如常,1日来发热38.5～39.9℃,无流涕咳嗽,仍有惊厥发生,其后嗓响有痰音,食纳差,二便正常,门诊疑为乙型脑炎而入院。既往体健,无头部外伤史,祖母曾患肺结核5年前已愈。家居农村,当地除农业耕作外以开采有色金属矿产为主。 体格检查:T39.8℃,P200次,R48次,BP13/8kPa,半昏迷状,呼吸急促,皮肤无皮疹及出血点,前囟已闭,巩膜无黄染,眼耳鼻咽口(一),心率200次,律齐无杂音,双肺布满痰鸣,腹软,肝在肋下3cm质软,脾(一),颈亢,右膝腱反射亢进,克氏征(一),布氏征(一),巴氏征(一)。
The boy, 1 year old and 1 month old, was admitted on August 18, 1994. Children with convulsions on the 3rd before the onset of the right limb twitch, mouth right oblique, staring eyes, ambiguity, sustained 1 hour after treatment to ease, 2 to attack many times, no fever, vomiting and diarrhea, relieve everything as usual , Fever on the 1st 38.5 ~ 39.9 ℃, no runny nose cough, there are still convulsions, followed by throat phlegm sound, poor appetite, two will be normal, outpatient suspected encephalitis and hospitalization. Past physical health, no history of head trauma, grandmother who had tuberculosis 5 years ago has been more. Home and rural areas, in addition to local farming outside the non-ferrous metal mining-based mining. Physical examination: T39.8 ℃, P200 times, R48 times, BP13 / 8kPa, semi-coma, shortness of breath, skin rash and bleeding point, the anterior fontanelle closed, scleral no yellow dye, Heart rate 200 times, law Qi no noise, lungs full of phlegm, abdominal soft liver in the ribs 3cm soft, spleen (a), hyperthyroidism, right knee tendon hyperreflexia, Kirschner sign (a) Levy (a), Pakistan’s sign (a).