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于××女44岁农民住院号852于1985年2月11日入院。10天前,患者在河边跌倒,左眼被芦根刺伤。在某医院诊断为左眼结膜撕裂伤。清创处理,球结膜下注射庆大霉素及肌注青霉素(未注破伤风抗毒素)。左眼肿痛渐重,创口有脓。第7天,不能张口,出现阵发性四肢抽搐,转入我院。既往无类似抽搐史。体检:T37.1℃,B.P130/90mmHg,神志清楚,苦笑面容,自动体位,张口一指,颈软,心肺无异常,肝脾未触及,神经系统未引出病理反射,四肢每小时有数次抽搐,每次持续10～30秒钟。化验:红细胞429万/mm~3,血色素13g%,白细胞8200/mm~3。
The female resident number 852, aged 44, was admitted on February 11, 1985. Ten days ago, the patient fell by the river and the left eye was stabbed by reed rhizome. In a hospital diagnosed as left conjunctival laceration. Debridement treatment, subconjunctival injection of gentamicin and intramuscular injection of penicillin (not tetanus antitoxin). The left eye is swollen and the wound has pus. The first 7 days, can not open mouth, paroxysmal limbs convulsions, transferred to our hospital. No previous history of similar convulsions. Physical examination: T37.1 ℃, B.P130 / 90mmHg, conscious, smile face, automatic position, a mouth open, neck soft, no abnormal heart and lung, liver and spleen not touched, the nervous system does not lead to pathological reflex, limbs several times an hour Twitch, each lasting 10 to 30 seconds. Laboratory: erythrocytes 4290000 / mm ~ 3, hemoglobin 13g%, white blood cells 8200 / mm ~ 3.