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患儿徐×,女,9个月,病案号45569。1990年7月5日出现无诱因的腹泻、发热。在当地用“PG 40万 u im Bid、黄连素 0.2po Tid”治疗,次日大便由黄色稀水便变为粘液血便,便次由10余次/日增加到30～40次/日。体温持续不退,最高达39℃。于7月7日以“急性细菌性痢疾”收住我科。病程中伴食欲减退。混合喂养,有饮用未处理塘水(小溪汇集而成)史。查体:T 39.5℃,体重6kg(出生体重3kg),营养稍差,皮下脂肪0.8cm.前囟轻度凹陷,口唇干燥,腹平坦,肠鸣活跃,心率132次/分,余体查正常。实验资料:大便常规:黄色带血稀便,粘液+,血液+;镜检:白细胞卅,红细胞卅。血常规:Hb9.1g%,WBC5300个/mm~3,N36%,L61%、M
Children Xu ×, female, 9 months, medical record number 45569. July 5, 1990 induced diarrhea, fever. In the local “PG 40000u im Bid, berberine 0.2po Tid” treatment, the stool the next day from the yellow water will become mucus bloody stool, then the times more than 10 times / day to 30 to 40 times / day. Sustained body temperature, up to 39 ℃. On July 7, we received “Acute Bacillary Dysentery” in our department. Course of the disease with loss of appetite. Mixed feeding, there is drinking untreated pond water (streams brought together) history. Examination: T 39.5 ℃, weight 6kg (birth weight 3kg), nutrition is slightly worse, subcutaneous fat 0.8cm. Anterior fontanel slightly depressed, dry lips, flat belly, bowel sounds active, heart rate 132 beats / min, remaining body check the normal . Experimental data: stool routine: yellow with loose stools, mucus +, blood +; microscopic examination: leukopenia, erythrocyte 卅. Blood: Hb9.1g%, WBC5300 / mm ~ 3, N36%, L61%, M