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病历摘要:患儿,男,6岁.因咳嗽、发热2个月余,头痛半月,头痛突然加重3天入院.患儿于入院前近2个多月来渐起咳嗽,痰液粘白.轻度发热,晚间盗汗.食欲差,消瘦.近半月来诉头痛,尚能下床活动.于入院前3天无明显诱因头痛突然加重,呕吐频发.起病以来,无咯血,曾经抗生素及对症治疗无效.既往史:平素体健,已接受计划免疫接种.无中耳炎、颅脑外伤史.家庭中现有肺结核患者.查体:T38.5℃,P110次/分,R26次/分,BP13/8kPa.神清,痛苦表情.发育正常,消瘦.皮肤粘膜无黄染及出血点、紫癜.浅淋巴结无肿大.头颅五官正常,耳鼻道无脓性分泌物.瞳孔等大等圆,对光反射灵敏.无紫绀,咽部(一),颈项强直.心律齐,心音正常.右肺呼吸音减弱.腹部(一),脊柱四肢
Patient, male, 6 years old. Due to cough, fever more than 2 months, headache and a half months, headache suddenly aggravated 3 days admission. Children in the hospital nearly 2 months before the onset of cough, sputum sticky. Mild fever, night sweats. Poor appetite, weight loss. Nearly half a month to complain of headache, still able to get out of bed activities. 3 days before admission no obvious incentive for a sudden increase in headache, vomiting frequent onset. Since hemoptysis, antibiotics and Symptomatic treatment is invalid. Past history: normal physical health, has received planned immunization. No history of otitis media, traumatic brain injury in the family of patients with pulmonary tuberculosis. Physical examination: T38.5 ℃, P110 beats / min, R26 beats / min, BP13 / 8kPa. God clear, painful expression. Normal development, weight loss. Skin and mucosa without yellow dye and bleeding, purpura. Superficial lymph nodes without swelling. Head and facial features normal, no purulent secretions. Pupil and other large circle, Sensitive to light reflection. No cyanosis, pharynx (a), neck stiffness. Qi Qi, heart sounds normal. Right lung breath sounds weakened. Abdomen (a), spine limbs