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病历摘要患儿,男,4(1/2)岁。1980年5月因肝大2厘米,谷丙转氨酶296单位(金氏法),诊断为无黄疸型肝炎入院。经保肝治疗,谷丙转氨酶降至正常出院。后因肝脾逐渐增大曾多处求医,均诊断为肝炎,给予保肝治疗。1981年3月开始出现不规则发热、皮疹、右侧颞部包块、双耳流脓血、腹部膨隆、肝脾肿大第2次入院,仍诊断肝炎、肝硬化、局部感染,经保肝和抗炎治疗无效而自动出院。1982年3月26日因肝脾肿大、全身皮疹、不规则发热加重并伴有眼球突出,颅骨缺损,咳嗽气喘,第3次入院。患儿为第3胎足月顺产,家族中无类似疾病。体检:体温39℃,精神萎靡,营养发育差,智力尚可,端坐呼吸,急性病容。头皮发际、胸背及腹部皮疹密集,表
Patient summary, male, 4 (1/2) years old. May 1980 due to liver 2 cm, alanine aminotransferase 296 units (King’s method), diagnosed as jaundice hepatitis admitted. After liver treatment, alanine aminotransferase reduced to normal discharge. After the liver and spleen gradually increased because of multiple medical treatment, were diagnosed with hepatitis, liver protection given. 1981 March began irregular fever, skin rashes, right temporal mass, purulent blood flow in both ears, abdominal bulging, hepatosplenomegaly second admission, still diagnosed with hepatitis, cirrhosis, local infection, the liver And anti-inflammatory treatment is invalid and discharged automatically. March 26, 1982 due to hepatosplenomegaly, systemic rash, irregular fever and exacerbations accompanied by prominent eyes, skull defects, cough and asthma, the third admission. Children with third-term fetus full-term follow-up, no similar disease in the family. Physical examination: body temperature 39 ℃, apathetic, poor nutritional development, intelligence is acceptable, sitting breathing, acute disease. Scalp hairline, chest and back and rashes intensive, table