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病历介绍 患者 男、18岁,学生,住院号101528。因右上腹疼痛、呕吐4天,意识障碍2天于1985年1月25日收住神经内科。 患者于1月20日突感右上腹隐痛,逐渐加重,2h后出现恶心,呕吐,呕出物为胃内容物。在当地按急性胃炎处理未能改善症状;翌日出现腹胀,1月23日夜出现烦燥不安,语言错乱。脑脊液(CSF)化验:外观清,潘氏(±),糖2.78mmol/L,有核细胞0.011×10~9/L。诊断为:“散发性脑炎”。给予甘露醇、糖皮质激素等治疗后恶心、呕吐停止。1月24日中午神志不清,二便失禁,遂转我院诊治。发病前两周有“上呼吸道感染”史。不嗜酒,未到过血吸虫流行区。
Patient male, 18 years old, student, hospital number 101528. Due to pain in the right upper quadrant, vomiting for 4 days, disturbance of consciousness 2 days in January 25, 1985 admitted to neurology. Patients on January 20 sudden sense of right upper quadrant pain, and gradually increased, after 2h nausea, vomiting, vomit for the contents of the stomach. Local treatment with acute gastritis failed to ameliorate symptoms; abdominal distension occurred the following day and irritability and language were disturbed on the night of January 23. Cerebrospinal fluid (CSF) assay: clear appearance, Pan (±), sugar 2.78mmol / L, nucleated cells 0.011 × 10 ~ 9 / L. Diagnosed as: “sporadic encephalitis.” Give mannitol, glucocorticoids and other treatment nausea, vomiting stopped. January 24 noon delirious, second incontinence, then transferred to our hospital for treatment. Two weeks before the onset of “upper respiratory tract infection” history. Do not drink, have not been to schistosome epidemic area.