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病历摘要女,11岁。不规则发热2周,咽痛、不能进食6天。2天前曾鼻衄2次,出血量不多,能自止。查体:T39.4℃,P124次,R26次。神清、精神萎靡。全身皮肤无皮疹及紫癜。两颌下可触及3～5个直径0.4～1.2cm大小的淋巴结,无粘连及触痛。头颅无异常,口臭,双侧扁桃体肿大Ⅰ°,无异常分泌物,咽腭弓上1/2,软腭后1/3处呈暗褐色坏死,无脓液,心肺(-)。肝肋下1.0cm,质软,轻压痛。脾未触及。神经系统正常。血RBC3.3×10~(12)/L,
Summary of medical record Female, 11 years old. Irregular fever 2 weeks, sore throat, can not eat 6 days. 2 days ago had nose 衄 2 times, small amount of bleeding, can stop. Physical examination: T39.4 ℃, P124 times, R26 times. Clear, apathetic. No skin rashes and purpura body. Under the two jaws can reach 3 to 5 diameter 0.4 ~ 1.2cm size of the lymph nodes, no adhesion and tenderness. No abnormalities in the skull, bad breath, bilateral tonsil enlargement I °, no abnormal secretions, pharyngeal palatal arch 1/2, 1/3 of the soft palate dark brown necrosis, no pus, cardiorespiratory (-). Liver ribs 1.0cm, soft, light tenderness. Spleen not touched. Nervous system is normal. Blood RBC3.3 × 10 ~ (12) / L,