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男婴,10个月,因阵发性抽搐2天,张口困难1天于87年11月25日入院。患者于入院前2天起无任何诱因出现四肢阵发性抽搐,强直。每次历时10余分钟,抽时哭闹,翌日出现吸吮时张口困难,精神萎糜,无发热、呕吐、昏迷。既往左中耳炎6个月余,至今未愈。查体:T37.4℃,R30次/分,发育正常,营养中等。神志清,呈苦笑面容,张口时门齿距0.8cm,左耳流脓。佛斯特氏征(一),心肺正常,腹(一),四肢肌张力增强,病理反射(一)。实验室检查:Hb108g/L,WBC8.4×10~9/L,N69%,L31%,血钙5.4mEg/L,脑脊液:压力40滴/分,潘迪氏(一),WBC3个/mm~3,糖68mg%,氯化物710mg%,临床诊断:耳源性破伤风,慢性化脓性中耳炎。
Baby boy, 10 months, due to paroxysmal convulsions 2 days, one day difficult mouth in November 25, 1987 admission. Patient in hospital from 2 days before the onset of any incentive to have paroxysmal convulsions, rigidity. Each time lasted more than 10 minutes, pumping when crying, the next day when sucking mouth opening difficulties, spiritual wilt, no fever, vomiting, coma. Past left otitis media more than 6 months, has not healed. Physical examination: T37.4 ℃, R30 times / min, normal development, moderate nutrition. Conscious, was smile face, mouth when the mouth width 0.8cm, left ear pus. Foster’s sign (a), normal heart and lung, abdomen (a), limb muscle tone increased, pathological reflexes (a). Laboratory tests: Hb108g / L, WBC8.4 × 10 ~ 9 / L, N69%, L31%, calcium 5.4mEg / L, cerebrospinal fluid pressure 40 drops / ~ 3, sugar 68mg%, chloride 710mg%, clinical diagnosis: ototoxicity, chronic suppurative otitis media.