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病历摘要患儿,女,11月。入院前20天因发热曾住他院用青霉素治疗未愈。6天前咳嗽,声嘶,双下肢无力不能扶站,神萎纳差。体检:T38℃,急性重病容,发育营养差,神萎,呼吸促,咽充血,双瞳等大,全身表浅淋巴结不肿大,颈软,气管居中,两肺可闻中细湿罗音,心率118次/分,律齐,肝肋下2cm,剑下3cm,质软,脾未扪及,双上肢肌力正常,双下肢肌力Ⅰ度,感觉减弱,膝反射减弱。血红蛋白97g/L,红细胞3.32×10~(12)/L,白细胞11.8
Medical record summary Children, female, November. 20 days before admission due to fever had his hospital treated with penicillin healed. 6 days ago cough, hoarseness, weakness in both lower extremities can not help station, Shen Shennao poor. Physical examination: T38 ℃, acute and severe disease, developmental poor nutrition, atrophy, shortness of breath, pharyngeal congestion, double pupil and other large, superficial lymph nodes are not swollen, neck soft, tracheal center, both lungs can be heard in the fine wet rales , Heart rate 118 beats / min, law Qi, liver ribs 2cm, sword 3cm, soft, spleen not palpable, normal upper limb muscle strength, lower extremity muscle strength Ⅰ degree, feeling weakened, knee reflex decreased. Hemoglobin 97g / L, red blood cells 3.32 × 10-12 / L, white blood cells 11.8