病历摘要患儿,女,19天,因发热4天入院。入院前3天开始发热,体温最高39℃。偶见双眼上吊,口角抽动,伴哭闹不安和吐奶。曾按“上感”治疗无效。第一胎第一产,足月顺产,生后无窒息。出生体重3.2公斤,牛奶喂养。母孕期健康,父患糖尿病一年余,无传染病接触史和有害物接触史。查体:体重2.9公斤,身长53厘米,头围34厘米。神志清,哭声尖,全身未见黄染及皮疹,前囟张力不高,面色灰,鼻搧(+),口周青,三凹征(-),咽红,呼吸44次/分,双肺呼吸音粗,未闻音,心界不大,心率156次/分,律齐,未闻杂音。腹软、肝肋下1.5厘米,脾未及。颈无抵抗。血红蛋白17 Medical records summary children, female, 19 days, admitted to hospital for 4 days due to fever. 3 days before admission fever, body temperature up to 39 ℃. Occasionally eyes hanging, mouth twitching, with crying and spit milk. Once press “sense” treatment is invalid. The first birth of the first child, term full-term, no suffocation after birth. Birth weight 3.2 kg, milk feeding. Pregnancy during pregnancy, father suffering from diabetes more than a year, no history of exposure to contagious diseases and exposure to harmful substances. Physical examination: weight 2.9 kg, length 53 cm, head circumference 34 cm. Sultry (+), mouth Zhou Qing, the three concave sign (-), throat red, breathing 44 times / min, the body is no yellow dye and rash, the anterior fontanel tension is not high, Breath sounds coarse lungs, did not hear the sound, the heart is not big, heart rate 156 beats / min, Law Qi, no unheard noise. Abdomen soft, liver ribs 1.5 cm, spleen and time. Neck without resistance. Hemoglobin