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病例摘要王××,女性,18岁,于1991年8月25日开始无任何诱因发热,持续在39℃左右,头胀痛,多次呕吐胃内容物。在当地医院给予抗感染、脱水降颅压治疗,病情逐渐加重,出现全身抽搐,尿失禁。以脑炎收住我科。既往轻度智力低下。查体:中等度昏迷,瞳孔等大,光反应存在,眼底视乳头境界欠清。BP:13/10kPa,R:28次/分,P:108次/分,T:39.4℃,左侧鼻唇沟变线,左侧肢体少动,右侧肢体出现多动,四肢肌张力增高,双侧 Babinskis 氏征阳性,颈强二横指。腰穿:压力正常,CST 外观无色透明,蛋白:0.55g/L,白细胞:18×
Case summary Wang × ×, female, 18 years old, started on August 25, 1991 without any incentive fever, sustained at about 39 ℃, head and neck pain, vomit stomach content. In the local hospital to give anti-infection, dehydration reduce intracranial pressure treatment, the condition gradually aggravated, systemic convulsions, urinary incontinence. Encephalitis with my department. Mild mental retardation. Physical examination: moderate coma, pupils and other large, light reaction exists, the status of the fundus as the lack of nipple. BP: 13 / 10kPa, R: 28 beats / min, P: 108 beats / min, T: 39.4 ℃. The left nasolabial fold changed line, the left limb moved less, the right limb appeared hyperactivity, , Bilateral Babinskis’s sign positive, neck strong two cross refers to. Waist wear: normal pressure, CST appearance colorless and transparent, protein: 0.55g / L, white blood cells: 18 ×