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病历摘要吕×,女,10岁,住院号71317。因腹泻一月余,发生休克于1973年3月18日21时35分来院急诊。患儿一月来开始腹泻,为稀水便,日6—7次。曾用黄连素、无味氯霉素、痢特灵等治疗无效。入院时体温不升。血压测不到。发育中等。营养差。神萎。面色苍白,紫绀,四肢末端厥冷,皮肤弹性差,两眼凹陷,呈中度脱水貌。巩膜无黄染。颈软。胸廓对称。心率84次/分,心音低钝,无杂音,心界不大。两肺少许湿罗音。腹部凹下,
Medical record summary LV ×, female, 10 years old, hospital number 71317. Because of diarrhea more than a month, the onset of shock at 21:35 on March 18, 1973 to hospital emergency room. Children with diarrhea in January to dilute the water, 6-7 times a day. Once with berberine, odorless chloramphenicol, furazolidone treatment ineffective. Admission body temperature does not rise. Blood pressure can not be measured. Medium development. Poor nutrition. Wilt. Pale, cyanotic, extremities Jueleng, skin elasticity is poor, his eyes hollow, was moderate dehydration appearance. Sclera without yellow dye. Neck soft. Thorax symmetry. Heart rate 84 beats / min, heart sound low blunt, no noise, the heart is not big. A little wet rales of both lungs. Abdomen concave,