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第一次查房(5月16日) 主治医师:请实习医师报告病历摘要。实习医师:患者女,7岁,住院号35598。因不规则发热月余于1987年5月14日入院。于4月10日受凉后开始发热,热型不规则,体温最高达40℃,无寒战,热退时无大汗,伴恶心、纳差,间有呕吐,吐出胃内容物,无腹痛和腹泻。在乡卫生院给青、链、红霉素等注射及中西药口服,治疗20多日体温不降,且日渐消瘦,面色苍白,一般情况变差,故转我院。病后无鼻衄、齿龈出血现象。既往健康,个人史、家族史无特殊。体检:T38.5℃,P105次/分,R28次/分,BP90/60mmHg。神志清,精神差,慢性消耗病
First round of ward (May 16) attending physician: ask an intern to report the medical summary. Intern: Female patient, 7 years old, hospital number 35598. Months due to irregular fever in May 14, 1987 admission. On April 10, it started to have fever after it cools. The fever type is irregular. The body temperature is up to 40 ℃. There is no chills, no sweating on fever, nausea, anorexia, vomiting between stomach and stomach, no stomach pain and diarrhea . In the township hospitals to the green, chain, erythromycin and other injection and Western medicine oral treatment of more than 20 days temperature does not fall, and the weight loss, pale, the general deterioration, it transferred to our hospital. No nose and throat after disease, bleeding gums. Past health, personal history, family history no special. Physical examination: T38.5 ℃, P105 beats / min, R28 beats / min, BP90 / 60mmHg. Consciousness, poor spirits, chronic consumption of disease