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病历摘要 患女10岁,以发热11d,腹痛、腹胀4d之主诉入院。11d前受凉后,流鼻涕、头痛、咳嗽、发热,在当地医院按上感治疗,应用青霉素,中药等治疗不见好转,高烧不退。5d前到某市医院住院治疗,按发热待查,应用青霉素和氨苄青霉素治疗仍不见效果。体温波动在37.5～40℃间,先寒战后高烧伴汗出。精神萎靡、纳差,呕吐每天1～2d次,大便呈糊状,每日1～2次。尿少色黄。当时查血、尿、粪常规,肝、肾功、心电图、胸片均未见异常,肥达反应阴性。入院前4d,腹痛明显,呈阵发性,伴腹胀难忍,故转我院治疗。
The summary of the patient suffering from female 10 years old, with fever 11d, abdominal pain, abdominal distension 4d the main complaint was admitted. 11d before the cold, runny nose, headache, cough, fever, according to the sense of the local hospital treatment, the application of penicillin, Chinese medicine and other treatment did not improve, high fever. 5d before going to hospital in a city hospital, according to fever pending investigation, the application of penicillin and ampicillin treatment still no effect. Fluctuation of body temperature between 37.5 ~ 40 ℃, after the first shiver with high fever with sweat. Apathetic, anorexia, vomiting 1 ~ 2d times a day, stool was a paste, 1 or 2 times a day. Urine less color yellow. At that time check blood, urine, fecal routine, liver, kidney function, electrocardiogram, chest X-ray showed no abnormalities, fat-negative reaction. 4d before admission, abdominal pain was obvious, paroxysmal, with abdominal discomfort, it turned to our hospital for treatment.