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病历摘要男性,3岁,因发热,阵发性抽搐14小时,昏迷、呼吸不规则7小时于1975年5月12日入院。患儿于入院当日6时出现高热、寒颤、神倦、继而嗜睡,面色改变,全身阵发性抽搐,持续约1时后呼吸促且不规则,唤之不醒。发病前否认咳嗽,呕吐和腹泻。个人史、家族史、既往史无特殊。体检:体温40℃,脉搏170次/分,呼吸48次/分,昏迷状态,呼吸不规则,面色苍白,躯干皮肤灼热,四肢冷,瞳孔左侧6mm,右侧4mm,对光反射消失,双眼眶下陷,颈软,心音低钝,双侧肺底部可闻密集湿罗音。肝右肋下1.5厘米,脾未触及,双侧膝反射、腹壁反射和提睾反射均消失。双侧巴彬氏征阳性。
Medical summary Male, 3 years old, due to fever, paroxysmal convulsions 14 hours, coma, irregular breathing 7 hours on May 12, 1975 admission. Children at 6:00 on the day of admission fever, shivering, God tired, and then drowsiness, complexion, systemic paroxysmal convulsions continued for about 1 o’clock after breathing and irregular, call wake up. Pre-onset denied cough, vomiting and diarrhea. Personal history, family history, no previous history. Physical examination: body temperature 40 ℃, pulse 170 beats / min, breathing 48 beats / min, coma, irregular breathing, pale, burning skin and trunk, cold limbs, pupil left 6mm, right 4mm, light reflex, Orbital sag, neck soft, low heart sound blunt, the bottom of both lungs can smell intensive wet rales. Liver right rib 1.5 cm, spleen not touched, both knee reflex, abdominal reflex and cremaster reflex disappeared. Bipin’s positive sign on both sides.