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患儿男性,2岁,因不规则发热、食欲不振、消瘦月余入院。查体:体温38℃,脉搏100次/分,呼吸40次/分。发育营养差,神清,不合作,触及患儿或更换体位时哭闹不止.呼吸稍促,未见发绀,面色苍白,面部及双下肢轻度浮肿,皮肤弹性差,未见出血点及淤斑。浅表淋巴结不大,口腔粘膜及咽部轻度充血,双肺底可闻及少许细湿啰音,心率100次/分,律齐未闻杂音。腹平软,无压痛,未扪及包块,肝肋下2cm、剑下4cm 可扪及,脾未触及。血象:血红蛋白5克,白细胞3990/mm~3,中性72%,淋巴28%。尿常规及肝功能正常。胸片示肺门淋巴结核并感染。入院后诊为:①肺门淋巴结核并感染,②Ⅲ度营养不良。给以抗感染、抗痨,纠正水电解质紊乱,以及补充营养等治疗。半月后咳嗽减轻,但体温不退,
Male children, 2 years old, due to irregular fever, loss of appetite, weight loss and more than admission. Physical examination: body temperature 38 ℃, pulse 100 beats / min, breathing 40 beats / min. Development of poor nutrition, God clear, non-cooperation, reach the children or change position when the crying more breath slightly, no cyanosis, pale, facial and lower extremity mild edema, skin elasticity is poor, no bleeding points and silt spot. Superficial lymph nodes are not, oral mucosa and pharynx mild congestion, lungs can be heard at the end and a little fine wet rales, heart rate 100 beats / min, Law Qi no unpleasant noise. Abdomen soft, no tenderness, no palpable mass, liver rib 2cm, sword 4cm palpable, the spleen not touched. Blood: 5 grams of hemoglobin, white blood cells 3990 / mm ~ 3, 72% of the neutral, lymphatic 28%. Urine and liver function is normal. Chest radiograph showed hilar lymph nodes and infection. After admission diagnosis: ① hilar lymph node and infection, ② Ⅲ degree malnutrition. To anti-infection, anti-tonic, correct water and electrolyte disorders, and nutritional supplements and other treatment. Half a month after the cough to reduce, but the body temperature does not refuse,