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病历摘要赵姓,男孩,5个月,陕西省人,于1959年3月18日以呕吐十余日、头向后仰、抽搐二日入院。患儿于入院二周前发烧,并伴有轻度咳嗽、眼红、流鼻涕,三日后全身出皮疹,疹型不详,疹后无高烧,但有呕吐,一日多次,呈喷射状,每次量多,为所食之物。疹子持续3—4日后渐退,仍一直呕吐,精神差,于入院前二日突然抽搐,共4次。吃奶差,大便稀,一日1—2次,无脓血。曾注射青霉素多次,剂量不详。既往体健,无发烧咳嗽病史,末接受任何预防接种。母乳喂养,量足,未加过任何辅食。家庭成员及周围接触人中未发现有结核及麻疹患者。体重6公斤,体温36℃,呼吸25次,脉搏110次。发育营养中等,神志清楚,精神萎靡,嗜睡,头向后仰,四肢屈曲,取侧卧位,全身皮肤触之过敏,无皮疹及色素沈着。全身淋巴结不肿大,前囟2×1.5厘米,膨隆紧张。眼、耳、鼻均无异常,咽稍
Medical history Zhao surname, boy, 5 months, Shaanxi Province, on March 18, 1959 to vomiting more than ten days, head backwards, convulsions admitted to hospital on the 2nd. Children with fever in the hospital two weeks ago, accompanied by mild cough, red eyes, runny nose, three days after the body a rash, rash type is not known, no high fever after rash, but vomiting, many times a day, was sprayed, each The amount of more for the food thing. Rash continued to decline after 3-4 days, still vomiting, poor spirit, convulsions on the 2nd day before admission, a total of 4 times. Poor feeding, loose stools, 1-2 times a day, no abscess blood. Penicillin has been injected several times, the dose is unknown. Past physical health, no history of fever cough, at the end of any vaccination. Breastfeeding, full, without any food supplement. No tuberculosis or measles patients were found in family members and surrounding persons. Weight 6 kg, body temperature 36 ℃, breathing 25 times, pulse 110 times. Development of moderate nutrition, conscious, apathetic, drowsiness, head back, limb flexion, take the lateral position, the skin allergies, no rash and pigmentation. Whole body lymph nodes are not enlarged, bregma 2 × 1.5 cm, bulging tension. Eye, ear, nose are normal, pharyngeal slightly