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病历摘要:男婴,9个月,陕西眉县籍, 于1986年2月5日入院。患儿于5天前开始腹泻,呈呈黄稀水便,无脓血,日3——4次,2日来高热,便次增存日十余次,为脓性,胀下堕感。查体:体温36.9℃,血压100/60,神志清,无脱水征,心、肺、腹检无异常发现。血红蛋白10.8克红脱胞384万,白细胞7400,中性62%,淋巴38%;粪常规检查为灰黄色粘液,镜检粘液+脓细胞+++,脂肪球+。入院诊
Medical records summary: Baby boy, 9 months, Shaanxi Meixian Ji, on February 5, 1986 admission. Children with diarrhea began 5 days ago, showed a yellowish water will be, no abscess blood, day 3 - 4 times, 2 days to heat, then times more than ten times deposit, purulent, swell falling feeling. Physical examination: body temperature 36.9 ℃, blood pressure 100/60, clear consciousness, no signs of dehydration, heart, lung, abdominal examination no abnormal findings. Hemoglobin 10.8 grams red 384 million, leukocyte 7400, neutral 62%, lymphatic 38%; fecal routine examination was gray-yellow mucus, microscopy mucociliary + pus +++, fat ball +. Admission