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病例介绍患儿鲍××女3月住院号40674 入院日期:1980年4月5日患儿因高热7小时,频繁抽搐5小时入院。体温最高达42℃(肛表),反复惊厥,神志不清伴腹泻、粘液便,血白细胞29800,粪常规白细胞+++,红细胞+。拟诊中毒性菌痢入院。体检:T39℃,P172次,R60次,BP80/50,皮肤无皮诊,巩膜无黄染,前囟紧张饱满,眼睛较小,有少量咖啡色液体从口鼻流出,颈软无抵抗,心率与脉搏相等,律齐,无器质性杂音闻及,两肺呼吸音粗糙,伴有湿罗音。腹软,饱满。肝肋下2.5cm,脾(-)。头围37.5cm。四肢、脊柱、外生殖器无明显异常。
Case description Children Bao × × female March hospitalization 40674 admission date: April 5, 1980 children with fever for 7 hours, frequent convulsions 5 hours admission. Body temperature up to 42 ℃ (anal table), repeated convulsions, delirious with diarrhea, mucus, blood leukocytes 29800, fecal conventional white blood cells +++, red blood cells +. To be diagnosed with toxic bacillary dysentery hospitalized. Physical examination: T39 ℃, P172 times, R60 times, BP80 / 50, skin no diagnosis, scleral no yellow dye, anterior fontanel tension, eyes are small, a small amount of brown liquid outflow from the nose and mouth, neck soft non-resistance, Equal pulse, law Qi, no organic noise smell, rough breathing sounds of both lungs, accompanied by wet rales. Abdomen soft, full. Liver ribs 2.5cm, spleen (-). Head circumference 37.5cm. Limbs, spine, external genitalia no obvious abnormalities.