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病历摘要患者肖某,女性,23岁,未婚,贵阳市人,汉族,工人。住院号:98987,因全身皮疹,发痒3个多月,发热一周,尿频、尿急、尿痛4天、于1979年7月29日住院。该患者3个多月前无任何诱因,在躯干及四肢,反复出现散在的红色丘疹,骚痒,可融合成片,能自行消退,在院外曾诊为“荨麻疹”,服药后未见好转。近一周来发烧、体温高达40.7℃,于4天前出现尿频、尿急、尿痛、食欲差等症状,在本院门诊做尿沉渣镜检结果:白细胞+,脓细胞+,红细胞1～6,按泌尿系感染在急诊室收留观察一天后住院。既往体健,无“结核”、伤寒”、“肝炎”等传染病史,月经史及家族史无特殊。体格检查:体温37.8℃,脉搏84次,血压100/70,营养中等,皮肤无黄染,背部、四
Patient summary Xiao Mou, female, 23 years old, unmarried, Guiyang City, Han nationality, workers. Hospital number: 98987, due to systemic rash, itchy more than 3 months, fever week, frequent urination, urgency, dysuria 4 days, on July 29, 1979 hospitalization. The patient more than 3 months ago without any incentives, in the trunk and limbs, repeatedly scattered red papules, itching, can be integrated into tablets, can be resolved on their own, has been diagnosed as “urticaria” outside the hospital, after taking no improvement . Nearly a week fever, body temperature as high as 40.7 ℃, 4 days ago urinary frequency, urgency, dysuria, poor appetite and other symptoms in our clinic urine urinary microscopy results: leukocyte +, pus +, red blood cells 1-6 , According to urinary tract infection admitted to the emergency room one day after hospitalization. Past physical health, no “tuberculosis”, “typhoid fever”, “hepatitis” and other infectious disease history, menstrual history and family history no special physical examination: body temperature 37.8 ℃, pulse 84 times, blood pressure 100/70, moderate nutrition, Back, four