论文部分内容阅读
病历摘要患者谢××,女,23岁,农民。因发热10天,于1970年9月5日入院。 10天前开始发热,体温达39℃。以后体温高低不一,每日波动范围在2℃左右,下午较高,伴畏寒。便溏,日解1～2次。无恶心、呕吐。曾在本院门诊注射青霉素、链霉素,因治疗无效而收住入院。过去身体健康,未去过血吸虫病流行区。体格检查:体温39.4℃,脉搏120次/分,呼吸20次/分,血压120/70毫米汞柱。急性病容,表情淡漠。未见皮疹。咽部不充血。心肺无异常。腹软,肝肋下2厘米,脾肋下1厘米,质均中等,无压痛。肾区叩击痛阴性。未引出病理神经反射。
Patient Xie × ×, female, 23 years old, farmer. Due to fever for 10 days, on September 5, 1970 admitted. 10 days ago fever, body temperature of 39 ℃. After the temperature varies, daily fluctuations in the range of 2 ℃, high in the afternoon, with chills. Convenient, daily solution 1 or 2 times. No nausea, vomiting. In our hospital outpatient penicillin, streptomycin, admitted to hospital for treatment invalid. Past in good health, have not been to schistosomiasis epidemic area. Physical examination: body temperature 39.4 ℃, pulse 120 beats / min, breathing 20 beats / min, blood pressure 120/70 mm Hg. Acute illness, expression of indifference. No rash. Pharynx is not congested. No abnormal heart and lung. Abdomen soft, liver ribs 2 cm, 1 cm under the spleen ribs, quality are medium, no tenderness. Kidney area percussion pain negative. Did not lead to pathological nerve reflex.