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1994年7月5日查房纪要——住院医师 请实习医师报告病历.实习医师 患儿,男,5岁,因面色苍白血尿,少尿3天,黄疸颜面浮肿2天入院.患儿10天前曾发热、呕吐、腹泻经输液治愈,近3天突然出现面色苍白,且逐渐加重,尿呈洗肉水样,量较少,曾肌注青霉素、止血剂治疗无效.查体:T36.2℃,HR86次/分,R18次/分,BP18/11kPa,精神萎糜,贫血貌,颜面轻度浮肿,巩膜轻度黄染,心音有力,心前区可闻及Ⅱ/ⅥSm,肺无罗音,肝右锁骨中线肋缘下1.5cm,脾未及,四肢无浮肿,指(趾)甲苍白,无病理征.辅助检查;血Rt:Hb55g/L,RBC18×10~(12)/L,WBC15.2×10~9/L,DC:N0.72,L0.28,BPC55×10~8/L,网织红细胞26.8%,血涂片可见RBC大小不等,多染,有核红细胞15%.血生化;Na~+132mmol/L,K~+5.8mmol/L,CI~-107mmol/L,CO_2-CP16mmol/L;ASO(—),肝功能正常,血总胆红素58.7μmol/L,
July 5, 1994 rounds summary - Resident physician please report medical records. Intern child, male, 5 years old, because of pale pale urine, oliguria 3 days, jaundice facial swelling 2 days admission. Children 10 days Previously fever, vomiting, diarrhea by infusion cure, pale suddenly appeared in the past 3 days, and gradually increased, urine was washed with water samples, less, had muscle injection of penicillin, hemostatic agents ineffective. ℃, HR86 beats / min, R18 beats / min, BP18 / 11kPa, spiritual wilt, anemia appearance, facial edema slightly, scleral mild yellow dye, strong heart sounds, precordial area can be heard and Ⅱ / Ⅵ Sm, Tone, right hepatic subclavian midline rib margin 1.5cm, splenometia and limbs without edema, finger (toe) A pale, no pathological signs. Assisted examination; blood Rt: Hb55g / L, RBC18 × 10-12 / , WBC15.2 × 10-9 / L, DC: N0.72, L0.28, BPC55 × 10-8 / L, reticulocyte 26.8%, blood smears showed RBC size range, more than dye, nucleated erythrocytes 15%, blood biochemistry, Na + 132mmol / L, K + 5.8mmol / L, CI -107mmol / L, CO 2 -CP 16mmol / L, ASO (-), normal liver function, total bilirubin 58.7μmol / L,