病历摘要病儿,男,11个月,因发热咳嗽2天,纳呆伴呕吐4次于1986年6月8日入院。病儿于入院前1天晨骤起发热,体温波动于38～39.5℃之间,伴咳嗽纳呆,今非喷射性呕吐4次,吐物为胃内食物,无惊厥、气促、腹泻等症状。在外曾应用磷霉素等治疗无效,今转来本院诊治。体检:体温37.8℃(肛温),脉搏126次,呼吸36次。急性病容,精神稍萎靡,神志清楚,面色略灰,全身无皮疹与瘀点,咽部充血,颈软,心音有力律齐,未闻病理杂音,两肺呼吸音粗糙,腹平软,肝在剑突下与肋下各3厘米,质软无触痛,脾在肋下2厘米,神经系统未见异常。实验室检查:血红蛋白10.5g/dl,红细胞340万/mm~3,白细胞5,600/mm~3,中性粒细 Medical records sick children, male, 11 months, 2 days due to fever, cough, 4 days with nevus and vomiting were June 8, 1986 admission. Sick children in the morning 1 day before admission, a sudden onset of fever, body temperature fluctuations between 38 ~ 39.5 ℃, with coughing asymptomatic today non-jet vomiting 4 times, spit things for the stomach, no convulsions, shortness of breath, diarrhea and other symptoms . Other applications such as fosfomycin treatment invalid, now transferred to our hospital for diagnosis and treatment. Physical examination: body temperature 37.8 ℃ (rectal temperature), pulse 126 times, breathing 36 times. Acute disease, the spirit of slightly sleepy, conscious, slightly gray, the whole body without rash and petechiae, throat congestion, neck soft, heart sound law Qi, no pathological murmur, rough breathing sounds of both lungs, abdominal soft, liver in the Under the xiphoid and ribs 3 cm, soft no tenderness, spleen 2 cm in the ribs, the nervous system showed no abnormalities. Laboratory tests: hemoglobin 10.5g / dl, erythrocyte 3.4 million / mm ~ 3, white blood cells 5,600 / mm ~ 3, neutropenia