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病历简介患者,男,1.5岁。日前感冒,其后咳嗽不止,并出现气喘、发热。急来社区卫生服务中心求治。初诊为肺炎,在家用药治疗。今日晚饭后不久,测量体温仍为39.2℃,于服药期间,突然发现患儿全身性强直-阵挛性发作,持续20秒左右缓解,之后呈轻度嗜睡状态。再次急来社区卫生服务中心。体格检查:体温39℃,脉搏114次/分,呼吸24次/分,血压100/78mmHg。发育正常,营养中等,精神萎靡,皮肤未见瘀点,全身浅表淋巴结未见肿大。巩膜无黄染,结膜苍白。双肺呼吸音弱,有散在湿性啰音。心率114次/分,律整,未闻及心脏杂音。腹部无压痛,无肌紧张及反跳痛。肝、脾未触及。肠鸣音正常。脊柱、四肢检查未见异常。
Patient history, male, 1.5 years old. Recently a cold, then more than cough, and asthma, fever. Emergency community health service center for treatment. Newly diagnosed as pneumonia, at home medication. Shortly after dinner today, the body temperature was measured at 39.2 ° C. Sudden onset of tonic-clonic seizures was found in the children during the medication period, lasting about 20 seconds, followed by mild drowsiness. Again urgent to community health service center. Physical examination: body temperature 39 ℃, pulse 114 beats / min, breathing 24 beats / min, blood pressure 100 / 78mmHg. Normal development, moderate nutrition, apathetic, no petechia skin, systemic superficial lymph nodes no enlargement. Sclera no yellow dye, conjunctival pale. Breathing lung sounds weak, scattered wet rales. Heart rate 114 beats / min, rhythm, no smell and heart murmur. Abdominal tenderness, no muscle tension and rebound tenderness. Liver, spleen not touched. Bowel sounds normal. Spine, limbs checked no abnormalities.