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患者陈××,男,63岁,退休工人,住院号48734,主诉:不规则低热2月伴头痛,频发呕吐三天,于83年6月2日收入住院。 入院检查:体温37.4℃,神清、痛苦面容,颈略抵抗,心率72次/分,血压130/80mmHg,两肺未闻及湿性罗音,肝、脾均未触及,其余无病理反射引出。 实验室检查:血、尿、大便常规均正常,肝功能正常,总胆固醇130mg％,甘油三脂64mg％,血尿素氮12mg％。 胸片显示两肺纹理稍多,两肺野无实变,膈及心脏未见异常。
Patient Chen × ×, male, 63 years old, retired worker, inpatient number 48734, chief complaint: Irregular fever with headache in February, Frequent vomiting for three days, June 2, 83 Income hospitalization. Admission examination: body temperature 37.4 ℃, God clear, painful face, neck slightly resistant, heart rate 72 beats / min, blood pressure 130 / 80mmHg, both lungs did not smell and wet rales, liver and spleen were not touched, the rest without pathological reflex leads. Laboratory tests: blood, urine, stool routine were normal, normal liver function, total cholesterol 130mg%, triglyceride 64mg%, blood urea nitrogen 12mg%. Chest radiograph showed slightly more than the two lungs, no changes in both lung fields, no abnormalities in the diaphragm and the heart.