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白××女 1岁住院号197。因发热、咳嗽5天,出疹3天,气喘伴烦躁不安1天,于1976年元月15日住潢川县医院。体查:体温38.2℃,脉搏212次/分(弱).呼吸T4次/分。神志不清,口唇明显发绀,全身暗红色斑丘疹尚隐约可见,“三凹”征显著。眼底小动脉痉挛。双肺底布满中小水泡音,心率212次/分,心音低钝。肝于右肋下锁骨中线上6厘米,剑突下5厘米,肝颈反流阳性。膝腱反射存在。诊断:麻疹出疹期合并肺炎、心力衰竭及中毒性脑病。
White XX female 1 year old hospital number 197. Due to fever, cough 5 days, rash 3 days, asthma with irritability 1 day, January 1976 1976 Huangchuan County Hospital. Physical examination: body temperature 38.2 ℃, pulse 212 beats / min (weak). Breathing T4 times / min. Consciousness, obviously cyanotic lips, dark red rash is still vaguely visible, “three concave” sign significant. Fundus arteriole spasm. Bottom of the lungs full of small and medium blisters sound, heart rate 212 beats / min, low heart sound blunt. Liver in the right rib subclavian midline 6 cm, 5 cm under the xiphoid, liver neck reflux positive. Knee tendon reflex exists. Diagnosis: Measles rash with pneumonia, heart failure and toxic encephalopathy.