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【病历摘要】高××,男,43岁。寒战、发热、咳嗽1天就诊。患者因乘火车出汗较多,下车后解衣乘凉,次日即感头痛、周身酸痛、寒战发热、恶心、咳少许黄痰;无流涕及鼻塞咽痛;无胸痛、胸闷及铁锈色痰,下午2时来我院急诊。查体:体温39.5℃,精神倦怠,咽部无明显充血,心肺正常。白细胞总数17600/立方毫米,中性粒细胞84%,有核左移,淋巴细胞16%,诊为“感冒”。给予复方扑尔敏1片,每日3次,青霉
【Summary】 medical records × ×, male, 43 years old. Chills, fever, cough 1 day treatment. Patients sweat more by train, getting off after uncoach, cool, the next day that headache, whole body soreness, chills fever, nausea, cough and little yellow sputum; no runny nose and nasopharyngeal sore throat; no chest pain, chest tightness and rust color Sputum, 2 o’clock in the afternoon to our hospital emergency room. Physical examination: body temperature 39.5 ℃, mental fatigue, no obvious throat congestion, normal heart and lungs. The total number of white blood cells 17600 / cubic mm, 84% of neutrophils, left nucleus, lymphocytes 16%, diagnosed as “cold.” Compound chlorpromazine given 1 tablet 3 times a day, Penicillium