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病历摘要女,15天,腹泻、发热4天。4天前患儿因喂养不当发生腹泻,为黄绿色稀水样便,30～40ml/次,5～6次/日,伴精神食欲差,最高体温38.5 C。15小时来呻吟,门诊查白细胞60,800,以“发热待查、败血症”住院。其母孕35周时因咯血住院,37周行剖腹产,出生体重3400g,1分钟Apgar10分,因“宝贵儿”转儿科。一般情况好,住院10天,出院时体重3500g。本次住院查体:T38.2℃,R48次,P136次,BP24mmHg,体重2500g。神清、呻吟,发育正常,营养中下,口干,发绀,前囟、眼窝凹陷。两肺呼吸音粗,心脏正常。腹膨隆,可见肠形及静脉怒张,肝肋下2cm,无压痛,脾未及,肠鸣音存在。四肢凉,皮肤无出
Female medical record, 15 days, diarrhea, fever 4 days. 4 days ago due to improper feeding in children with diarrhea, yellow and green watery stools, 30 ~ 40ml / time, 5 to 6 times / day, with poor mental appetite, the highest temperature 38.5 C. 15 hours to moan, outpatient check white blood cells 60,800, “fever pending, sepsis” hospitalization. The mothers were hospitalized for hemoptysis at 35 weeks and caesarean section at 37 weeks. The birth weight was 3400g and Apgar10 minute for 1 minute. Generally good, hospital 10 days, weight 3500g discharged. The hospital examination: T38.2 ℃, R48 times, P136 times, BP24mmHg, weight 2500g. Clear, moaning, normal development, nutrition in the next, dry mouth, cyanosis, anterior fontanel, orbital depression. Breath sounds coarse lungs, normal heart. Abdominal bulge, visible intestinal and vein engorgement, liver ribs 2cm, no tenderness, spleen and bowel sounds, bowel sounds exist. Cold limbs, no skin