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1病历摘要男,15岁。因腹泻、头痛、恶心、呕吐伴发热2 d入院。2 d前受凉后出现腹泻黄色稀便,无腹痛,经治腹泻减轻,但出现头痛,恶心,喷射状呕吐胃内容物,伴发热,为诊治收住院。查体:T 39.8℃,神清,反应迟钝,头、双眼偏向右侧,双瞳孔0·2 cm,颈阻,心肺腹正常,右侧肢体肌张力增高,
1 medical record summary male, 15 years old. Due to diarrhea, headache, nausea, vomiting with fever 2 d admission. 2 d before the cold appeared diarrhea yellow loose stools, no abdominal pain, relieve diarrhea, but headache, nausea, vomiting stomach contents spray, with fever, admitted for hospitalization. Examination: T 39.8 ℃, Shen Qing, unresponsive, head, eyes biased to the right, double pupil 0.2 cm, neck resistance, cardiolipinus normal, right limb muscle tension increased,