Medical number: 703066Main diagnosis: invasive enteritis, myocarditis, metabolic acidossHistory summary:Female, 6-month and 12-day old.Mainomplainsdiaaorondaywithfe,andbloodystoolforhafayThepatientpresents in our wardwith chief complaintof diarrhea,highfever (38.9°C),bloodystool. Small quantity of green, watery, mucous stool with a fequency of 10+times per day hasshowed blood streak, and is terminated with a few drops of blood drops in bright red. The4.patntapmat finddffekfiagesousplemdntasyafbshsupplouontpptifeeding, and contacting atient with chronicdiaheaaredeniedPhysical examinationhykinNeck:no neck stiffnessPharyngeal:congestiorChestcrackles at both sides of lung fieldsHeart:Regular rate and rhythm, no murmur, first het sound decreaseAbdomen:Sof without tender or hepatosplenomegaly.Genitourinary: Normal.Rectal:Anus fissure6.Laboraminatio, WBC (++) RBC (+++), Igen (-), occult blood (+)StoolRoutine:bloodBlood Routine: WBC 12.8x10°/L, N0.65 L0.35, Hb101g/L, CRP36mg/LBlood gas analysis: pH7.27, HCO: 20.2mmol/L, BE:-6.7mmol/L,BE:-6.6mmol/L,sHCO3-:17.9mmol/L, spO2 0.26,lactic acid: 3.9mmol/LCK-MB:19.2U/lLiver function test: normaRenal function test: normal.Blood electrolytes: normal.TreatmentsControl infection: antibiotics (Cefopiramide, Amoxicllin and Clavulanate Potassium)2Support therapCreatine Phosphate Sodium).(1)Myocardier(2) Liquid and electrolyte balance.Outcome:Diarrhaisstoppedonthorthdayopitalizationndmentalstateappetitefthpatienarerecovered with loose butnot watery,mucous stool and without fever or vomitingFollow-upIt was asked to investigate stool and heart rate, rhythm in outpatient 2 weeks after checkingout
Medical number: 703066 Main diagnosis: invasive enteritis, myocarditis, metabolic acidosis History summary: 1. Female, 6-month and 12-day old. 2. Main complaints: diarrhea for one day with fever, and bloody stool for half day. 3. The patient presents in our ward with chief complaint of diarrhea, high fever (38.9℃), bloody stool. Small quantity of green, watery, mucous stool with a frequency of 10+times per day has showed blood streak, and is terminated with a few drops of blood drops in bright red. The 4. patient vomits and feels Contaminated food feeding, complementary food supplement, tenesmus, tiredness and shows poor appetite. overfeeding, and contacting of patient with chronic diarrhea are denied. 5. Physical examination: Vital Signs: Temperature 38.5℃, Respirations 35, heart rate 120, Weight 8kg. General: Awake, no sunken fontanel and eyes, no dry or sticky mouth, no dry skin. Neck: no neck stiffness. Pharyngeal: congestion. Chest: no crackles at both sides of lung fields. Heart: Regular rate and rhythm, no murmur, first heart sound decreased. Abdomen: Soft without tender or hepatosplenomegaly. Genitourinary: Normal. Rectal: Anus fissure 6. Laboratory examination: Stool Routine: blood streak, WBC (++) RBC (+++), rotavirus antigen (-), occult blood (+). Blood Routine: WBC 12.8×109 /L, N0.65 L0.35, Hb101g/L, CRP36mg/L. Blood gas analysis: pH7.27, HCO3 - 20.2mmol/L, BE: -6.7mmol/L, BE: -6.6mmol/L, sHCO3-:17.9mmol/L, spO2 0.26, lactic acid: 3.9mmol/L, CK-MB: 19.2U/L. Liver function test: normal. Renal function test: normal. Blood electrolytes: normal. Treatments: 1. Control infection: antibiotics (Cefopiramide, Amoxicillin and Clavulanate Potassium). 2. Support therapy: (1) Myocardial recovery (Creatine Phosphate Sodium). (2) Liquid and electrolyte balance. Outcome： Diarrhea is stopped on the forth day of hospitalization, and mental state, appetite of the patient are recovered with loose but not watery, mucous stool and without fever or vomiting. Follow-up: It was asked to investigate stool and heart rate, rhythm in outpatient 2 weeks after checking out