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患者李××,女,22岁,未婚,某野战医院护士。住院号:18376。主诉:间歇性头痛4天入院,4天前曾患感冒,全身酸痛无力,伴咽干,流清鼻涕,经门诊治疗,除头痛未能减外,其他症状消失,头痛放射至右侧头面及耳颞部并阵发性疼,疼痛时间短,间歇时间长,对外界刺激无明显诱因,以晚上10时至凌晨2点头疼较剧。既往身体健康、无头痛及三叉神经疼痛病史。口腔颌面部检查:两侧面颊部对称,双侧鼻腔粘膜无红肿,通气尚好,无脓涕,右侧眶下尖牙凹:鼻翼外侧0.8cm处,有上颌骨骨质膨隆感,压痛(?),张口度和咬(牙合)关系如常,上下牙列排列整齐,未见有
Patient Lee × ×, female, 22 years old, unmarried, a field hospital nurse. Hospital number: 18376. Chief Complaint: Intermittent headache 4 days admission, 4 days ago had a cold, body aches and weakness, accompanied by throat dry, flowing nose, after outpatient treatment, in addition to headache failed to reduce the other symptoms disappear, headache and radiate to the right side of the head and Ear and temporal paroxysmal pain, pain time is short, long intermittent, no obvious incentive to the outside world to 10 o'clock in the morning to 2:00 headache more drama. Previous physical health, no headache and history of trigeminal pain. Oral and maxillofacial examination: both sides of the cheek symmetry, bilateral nasal mucosa without swelling, ventilation is good, no purulent nasal discharge, right infraorbital fangalysis: 0.8cm lateral to the alar wing, maxillary bone swelling, tenderness (tenderness ?), Mouth opening and bite (occlusion) relationship as usual, the upper and lower dentition arranged neatly, there is no