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患儿,女,3岁。以“反复咳喘2年,加重伴发热3d”之代诉于1992年9月21日收住我科。即往有中耳炎病史,父母体健。查体:体温37.8℃,精神差,呼吸稍促,口后微发绀。浅表淋巴结不肿大。双侧上颌窦压痛明显。胸廊对称,双肺呼吸音粗糙,布满中小水泡音。心尖搏动在右侧第四肋间锁中线外1cm处,心率120次/min,律齐、心音钝,无杂音。腹平软,肝脏于左侧锁中线上肋缘下1.5cm质软。神经系统阴性。Hb12g/L,RBC4.1×10~(12)/L,WBC7.5×10~9/L,N0.44,L0.56。心电图符合右位心改变。胸腹部X线检查示:支气管肺炎,右位心,肝脏位于左侧,胃泡在右上腹部。鼻窦瓦氏位片示:双侧上颌窦炎伴积液。入院后给予青霉素、氨苄青霉素抗感染治疗,咳喘症状逐渐减轻,体温正常,肺部感染控制,治疗10d出院。
Children, female, 3 years old. To “repeatedly cough 2 years, aggravating fever with 3d” on September 21, 1992 admitted to our department. To the history of otitis media, parental health. Physical examination: body temperature 37.8 ℃, poor spirit, breathing a little urgency, micro-cyanosis after oral administration. Superficial lymph nodes are not enlarged. Bilateral maxillary sinus tenderness significantly. Symmetrical chest, lungs breathing sound rough, full of small and medium blisters sound. Apex beat in the right intercostal lock 1cm at the midline, heart rate 120 beats / min, law Qi, heart sound blunt, no noise. Abdomen soft, liver on the left side of the central line of the rib under the margin of 1.5cm soft. Nervous system negative. Hb12g / L, RBC4.1 × 10-12 / L, WBC7.5 × 10-9 / L, N0.44, L0.56. ECG consistent with right concentric change. X-ray examination of chest and abdomen showed: bronchial pneumonia, right ambition, the liver is located on the left, stomach in the right upper abdomen. Vasovagal sinusitis film shows: bilateral maxillary sinusitis with effusion. After admission to give penicillin, ampicillin anti-infective treatment, Cough symptoms gradually reduced, normal body temperature, pulmonary infection control, treatment 10d discharged.