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患儿郭×,男性。生后4天,因不吃4天,于第3天发烧,抽搐1次,经积极抢救治疗烧退,仍不吃,张口受限,于1983年11月25日入院。其母有先兆流产,应用黄体酮保胎,妊娠5个月发烧,羊水过多,曾2次B超检查,过月18天行剖腹产。体检:外观正常新生几,体温36℃,啼哭时不能张大,牙关紧闭打不开,前囱较小,颈软,曾请外科会诊2次均排除破伤风。吮吸反射,拥抱反射均消失,双下肢肌张力增强,右侧口角处裂口1 cm,张口度0.3cm。实验室检查:血色素190g/l,白血球20×10~9/l,中性0.70,淋巴0.28,酸性0.02,出血时间1 min,凝血时间1min。入院治疗经过:患儿入院后,给予氨苄青霉素抗感染治疗,血培养无细菌生长,请外科医师会诊,排除新生几破伤风,经过抗感染治疗后,患儿张口度恢复正常,吃奶好,双下肢活动自如,于1983年12月5日出院。
Children Guo ×, male. 4 days after birth, due to eat 4 days, on the 3rd day of fever, convulsions 1, after active rescue treatment regurgitation, still do not eat, mouth restricted, in November 25, 1983 admission. The mother has threatened abortion, the application of progesterone miscarriage, pregnancy 5 months fever, polyhydramnios, had 2 B-ultrasound, cesarean section on the 18th of the month. Physical examination: the appearance of a normal newborn, body temperature 36 ℃, crying can not be large, closed tight opening can not open, the former small fins, neck soft, had surgery consultation twice ruled out tetanus. Sucking reflex, hug reflex disappeared, double lower extremity muscle tone enhancement, the right side of the mouth cleft 1 cm, mouth opening 0.3cm. Laboratory tests: hemoglobin 190g / l, white blood cells 20 × 10 ~ 9 / l, neutral 0.70, lymphatic 0.28, acid 0.02, bleeding time 1 min, clotting time 1min. Admission treatment after: Children admitted to hospital, give ampicillin anti-infective treatment, blood culture without bacteria growth, please surgeon consultation, ruled out a few newborn tetanus, after anti-infective treatment, children mouth mouth returned to normal, good feeding, Both lower extremities freely, was discharged on December 5, 1983.