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秦××女,11月,住院号4128。因反复发热半个月,咳嗽腹泻3天入院。入院体查:T38.7℃、R28次,P152次、体重5.5公斤。神清,发育欠佳,Ⅱ°营养不良,贫血貌,皮肤弹性稍差。全身浅表淋巴结不大;头颅大小正常,前囟未闭合呈1×1cm;眼结膜无充血;双侧瞳孔对光反射存在,等圆等大;鼻正常;耳无特殊。咽充血(+),扁桃体不大,口唇稍干燥。颈软,气管居中,无颈静脉怒张;胸廓对称,双侧肋骨下段明显,星串珠状;双肺呼吸音粗,未闻及干湿啰音;心尖搏动正常,心界不大,心脏各瓣膜区未触及震颤,心率152次,律整,心尖部可闻吹风样收缩期杂音Ⅱ级;腹平软,未发现肠型及包块,肝右肋下3cm,质软,脾触诊不满意,肠鸣音稍亢进,四肢脊柱正常,神经系统检查无特殊发现。血常规:WBC12100,N44%,L56%,RBC181万,Hb5g;大
Qin × × female, November, hospital number 4128. Due to repeated fever for half a month, cough and diarrhea admitted to hospital for 3 days. Admission investigation: T38.7 ℃, R28 times, P152 times, weight 5.5 kg. God clear, poorly developed, Ⅱ ° malnutrition, anemia, skin elasticity slightly less. Systemic superficial lymph nodes is not large; normal skull size, anterior fontanel not closed was 1 × 1cm; conjunctival hyperemia; bilateral pupil light reflexes exist, such as large circle; normal nose; ears without special. Pharyngeal congestion (+), tonsil is not big, lips slightly dry. Neck soft, the middle of the trachea, no jugular vein engorgement; symmetry of the thorax, bilateral lower ribs obvious, star beads; lung breath sounds coarse, no smell and wet and dry rales; apex beat normal, Valvular area did not touch the tremor, heart rate 152 times, the law, the apex can be heard hair-like systolic murmur Ⅱ level; abdominal soft, no intestinal type and mass, the right rib 3cm, soft palpation do not palpate Satisfied, slightly hyperactive bowel sounds, normal limbs spine, nervous system examination found no special. Blood: WBC12100, N44%, L56%, RBC181 million, Hb5g; large