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病历摘要朱××,男,9岁,遂平县人,因7日来发烧、流涕、头痛,一天来口眼歪斜,吞咽困难、走路不稳,于1980年12月9日入院.入院前一周病儿开始低烧、打喷嚏、咽痛、头痛,当时在大队卫生室用复方阿司匹林片治疗后,体温正常,又继续上学。发病第7天,家长发现患儿右眼闭合不严,喝水发呛,吞咽困难,语言不清,四肢活动尚可,但走路不稳,形如醉汉,食欲尚可,余无异常.因在公社卫生院诊断不明,随转我院,门诊以“面神经麻痹”收住内儿科。既往史:未患过麻疹,肺结核和绦虫病,家长否认有吃“米猪肉”史、蜊蛄和石蟹史,大便中从未发现过绦虫妊娠节片,生后至今一直在遂平.家中父母兄姐健在.体检:T36.4℃,P80次/分,R16次/分,BP90/60mmHg。发育正常,营养中等,神志清楚,表情淡漠。右眼不能外展,两眼球向各方向均有震
Summary of medical records Zhu × ×, male, 9 years old, Suiping County, had a fever, runny nose and headache on the 7th and had mouth-to-eyes skewness, swallowing difficulties and walking instability on the 7th and was admitted on December 9, 1980. In the previous week, the sick child started to have a fever, sneezing, sore throat and a headache. After treatment with compound aspirin in the brigade’s health clinic, the temperature was normal and he continued to go to school. On the seventh day of onset, parents found that the right eye of the child was closed, the water was choking, swallowing difficulties, the language was unclear, and the activities of the limbs were acceptable. However, walking was not stable and the shape was like a drunkard. Because of the unknown in the commune health clinic, with the transfer to our hospital, outpatient “facial paralysis” to receive internal pediatrics. Past history: No measles, tuberculosis and taeniasis, parents denied having a history of eating “rice pork”, clams and crab history, never found in the feces of tapeworm Pregnancy Festival tablets, has been in post-natal Suiping. Sister health in. Physical examination: T36.4 ℃, P80 beats / min, R16 beats / min, BP90 / 60mmHg. Normal development, moderate nutrition, conscious, apathy. Right eye can not be outreach, both eyes are shocked in all directions