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病历摘要:谈×,男,一岁,住院号39041。因下肢活动不灵,哭闹四天,发热一天于1977年2月8日入院。四天来病儿每于夜晚啼哭、抓头哭闹,随后发现右下肢不能站立。曾于当地医院就诊疑为“小儿麻痹症,”用加芝他敏、地巴唑等无效而转来我院。既往史:第二胎第二产,平时健康,母乳喂养,未加辅食,病前已能扶站,接种过卡介苗。无结核接触史。入院检查:体温39℃(R)发育及营养中等,神志清,精神如常。前(?)未闭1×1厘米,无紧张或膨隆,已长二牙。颈软,咽部稍充血,心肺无异常
Medical record summary: about ×, male, a year old, hospital number 39041. Insomnia due to lower limbs, crying for four days, one day fever in February 8, 1977 admission. Every four days sick child crying every night, scratching his head and crying, then found the right leg can not stand. Visited the local hospital suspected of “poliomyelitis,” with Ji Zhi Min, methimazole invalid and transferred to our hospital. Past history: the second child of the second production, usually healthy, breastfeeding, without complementary food, can help stop before the disease, vaccinated BCG. No TB contact history. Admission examination: body temperature 39 ℃ (R) development and nutritional medium, conscious, the spirit of normal. Before (?) Not closed 1 × 1 cm, no tension or bulging, has long two teeth. Neck soft, slightly hyperemic pharynx, no abnormal heart and lung