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病历摘要患儿女性,3个月,江苏太仓人,因持续发热2个月,腹泻呕吐1周,于1986年4月23日入院。患儿系第一胎,第一产,足月顺产,出生体重4kg,生产史无特殊。生后第4周起发热,无其他伴随症状,体温38℃～40℃,曾在当地医院多次就诊,两次短期住院治疗,诊断为“败血症,尿路感染。”尿培养有大肠杆菌生长,经多种抗生素治疗无效来上海就诊,具体治疗情况和化验结果不详。入院一周前出现腹泻2～4次/日,黄色稀便,伴非喷射性呕吐,为胃内容物,小便色深,无咳嗽气急、无抽痉等,患儿系人工喂养儿,未接受任何预防接种等。体检:慢性消耗性病容,体重5kg,体温36.2℃(R)。皮肤轻度黄疸,双侧臀部及大腿内侧见陈旧性
Medical records Abstract Children and adolescents, 3 months, Taicang, Jiangsu, was admitted to hospital on April 23, 1986, due to persistent fever for 2 months and diarrhea and vomiting for 1 week. Children with the first child, the first birth, term full-term, birth weight 4kg, no history of production. 4 weeks after birth, fever, no other accompanying symptoms, body temperature 38 ℃ ~ 40 ℃, multiple visits at a local hospital, two short-term hospitalization, diagnosed as “sepsis, urinary tract infection.” Urinary culture with E. coli growth , After a variety of antibiotic treatment to Shanghai for treatment, the specific treatment and laboratory results unknown. A week before admission diarrhea 2 to 4 times / day, yellow loose stools, with non-jet vomiting, stomach contents, dark urine, no cough and shortness of breath, no spasms, etc., children were artificial feeding children, did not receive any Vaccination and so on. Physical examination: chronic wasting disease, weight 5kg, body temperature 36.2 ℃ (R). Skin mild jaundice, bilateral hip and thigh see the old