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病史摘要卜××,女,17岁,学生,住院号119933。于1969年9月上旬骤起高热伴寒战,流涕,持续2周。某院曾给服四环素、退热剂,热不退,而颈部淋巴结逐见肿大。虽改用抗结核治疗,体温仍徘徊在38.5～39.5℃,并伴有肝脾肿大。疑为肠伤寒、淋巴瘤收住入院。既往史无特殊。入院体检:营养发育正常,神志清。血压110/70,脉搏98次,体温38.9℃。皮肤粘膜未见出血点及皮疹,颌下淋巴结肿大,右颈部可触及多个黄豆或蚕豆大小淋巴结,质地中等,轻度触痛,无粘连。颈软,心肺正常,腹平软,无压痛。肝肋下1.5cm,剑突下3.0cm,质软,无结节,脾肋下2.5cm,质中。腹水征阴性。神经系统体征阴性。
Summary of medical history Bu × ×, female, 17 years old, student, hospital number 119933. In early September 1969 sudden high fever chills, runny nose, lasted 2 weeks. A hospital had served tetracycline, antipyretics, heat, and neck lymph nodes by swollen. Although the switch to anti-TB treatment, body temperature is still hovering at 38.5 ~ 39.5 ℃, accompanied by hepatosplenomegaly. Suspected typhus, lymphoma admitted to hospital. No previous history. Admission medical examination: normal nutrition, conscious mind. Blood pressure 110/70, pulse 98 times, body temperature 38.9 ℃. No skin and mucous membrane bleeding and rash, submandibular lymph nodes, the right neck can reach a number of soybean or broad bean size lymph nodes, medium texture, mild tenderness, no adhesions. Neck soft, normal heart and lungs, abdominal soft, no tenderness. Liver ribs 1.5cm, xiphoid 3.0cm, soft, non-nodular, spleen ribs 2.5cm, quality. Ascites sign negative. Nervous system signs negative.