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杜××,男,3岁零6月,住院号88245。患儿发热7天,伴面色苍白,于1988年7月18日以“贫血原因”,“白血病”待查收入院。患儿于8天前因“感冒”后发热,体温达39℃以上,无流涕、咳嗽、腹痛、腹泻、无呕吐、无鼻衄、黑便,未服用任何药物。患儿面色进行性苍白、尿黄如茶。体查T:39.5℃,R30次/分,P150次/分,体重12.5Kg,发育正常,营养差,急性病容,贫血貌,皮肤粘膜苍白,无黄染及出血点,浅表淋巴结不大,巩膜无黄染,脸结膜苍白,颈软,胸骨柄无压痛,双肺呼吸音清,心率150次/分,律齐。腹平坦,软,
Du × ×, male, 3 years and 6 months, hospital number 88245. Children with fever 7 days, with pale, on July 18, 1988 to “anemia causes”, “leukemia” to be admitted to hospital. Children 8 days ago because of “cold” after fever, body temperature up to 39 ℃, no runny nose, cough, abdominal pain, diarrhea, no vomiting, no nose and throat, melena, not taking any drugs. Children pale complexion, urine yellow, such as tea. Physical examination T: 39.5 ℃, R30 beats / min, P150 beats / min, weight 12.5Kg, normal development, poor nutrition, acute disease, anemia appearance, skin mucosa pale, no yellow dye and bleeding, superficial lymph nodes, Sclera no yellow dye, pale face conjunctiva, neck soft, no tenderness of the sternum, lung breath sounds clear, heart rate 150 beats / min, law Qi. Belly flat, soft,