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患者女,31岁,因鼻塞、流涕、咳嗽、畏寒就诊。查体:体温37.9℃,心率89次/min,呼吸24次/min,血压140/60mmHg(1mmHg=0.133kPa)。一般情况尚可,神志清楚,精神欠佳。胸廓对称,呼吸稍促,两侧肺部呼吸音粗糙,闻及少许哮鸣音。心脏及腹部检查未见明显异常,神经系统检查均正常。实验室检查:血常规WBC12.5×109/L,余(-)。尿常规、大便常规无异常。心电图示:大致正常心电图。诊断上呼吸道感染。治疗:0.9%生理盐水200mg,克林霉素磷酸酯
Female patient, 31 years old, due to nasal congestion, runny nose, cough, chills treatment. Examination: body temperature 37.9 ℃, heart rate 89 beats / min, breathing 24 times / min, blood pressure 140 / 60mmHg (1mmHg = 0.133kPa). The general situation is acceptable, conscious, unscrupulous. Symmetrical thorax, breathing a little faster, both sides of the lungs rough breathing sounds, smell a little wheeze. Heart and abdominal examination showed no obvious abnormalities, nervous system tests were normal. Laboratory tests: blood WBC12.5 × 109 / L, I (-). Urine, stool routine without exception. ECG shows: roughly normal ECG. Diagnosis of upper respiratory tract infection. Treatment: 0.9% saline 200mg, clindamycin phosphate