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病案举例蒋××,男,30岁,农民,西安人,住院号54051,1979年10月27日以发冷发烧,头痛、心口痛、恶心4天主诉入院。4日前无原因头痛、发冷发烧,心口痛、胸闷,不能进食、在大队医疗站按“感冒”、“胃炎”治疗无效,昨日病情加重,下午发现胸部有散在出血点。尿蛋白少量,脓球“+”,白细胞6,200/mm~3,中性69%,淋巴28%,单核3%,血小板9.3万/mm~3,以“出血热”入院。素健,否认肝炎病史,家住出血热流行区。体格检查:T39.5℃,BP110/70mmHg,R30次/分,P80次/分,神志清楚,巩膜皮肤无黄染,球结膜无充血水肿,胸部、腋下未见出血点,咽部充血潮红。心肺未发现异常。腹
An example of a medical case Jiang XX, male, 30 years old, farmer, Xi’an, hospital number 54051, October 27, 1979 with chilly fever, headache, chest pain, nausea 4 days chief complaint. 4 days ago no reason for headache, chills fever, chest pain, chest tightness, can not eat, press the “cold” in the brigade medical station, “gastritis” treatment is invalid, the condition worsened in the afternoon found the chest with scattered bleeding point. A small amount of urinary protein, pus ball “+”, white blood cells 6,200 / mm ~ 3, 69% neutral, lymphatic 28%, mononuclear 3%, platelet 93000 / mm ~ 3, to “hemorrhagic fever” admission. Su-health, denied the history of hepatitis, who live in hemorrhagic fever epidemic area. Physical examination: T39.5 ℃, BP110 / 70mmHg, R30 beats / min, P80 beats / min, consciously, sclera skin no yellow dye, bulbar conjunctiva without congestion and edema, chest, armpit no bleeding, swollen pharynx . Cardiopulmonary no abnormalities found. belly