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患者男性,22岁,汉族,工人,住院号30282。因发热,头痛,纳差6天于1984年2月3日就诊入某院。诉6天前受凉后发热头痛,2天后每天寒战发热出汗2—3次,体温下降不正常,在该院按“感冒”用青、庆霉素治疗。因热不退,头痛加重转来我院。起病后入睡困难,纳差,二便正常,无鼻阻、流涕,咳嗽。既往身体健康,幼年患过“肝炎”,有结核接触史,无药物过敏。体检:T 38.5℃,P 100次/分,R 20次/分,BP100/70mmHg,发热面容,神志清,表浅淋巴结正常。咽充血明显,扁桃体正常,无炎性分泌物。心肺正常。腹平,肝脾未扪及,四肌无压痛,关节活动正常。临床诊断:地方性斑疹伤寒。实
Male patient, 22 years old, Han nationality, worker, hospital number 30282. Due to fever, headache, anorexia 6 days in February 3, 1984 to a hospital. V. 6 days before the cold headache after fever, fever, fever, sweating 2 to 3 times a day after the fever, fever, temperature drop is not normal, in the hospital by the “cold” with cyanobacteria treatment. Due to heat, my headache aggravate transferred to our hospital. After falling asleep difficulties, anorexia, two will be normal, no nose resistance, runny nose, cough. Past physical health, juvenile suffering from “hepatitis”, history of exposure to tuberculosis, no drug allergy. Physical examination: T 38.5 ℃, P 100 beats / min, R 20 beats / min, BP100 / 70mmHg, fever face, clear consciousness, superficial lymph nodes normal. Pharyngeal congestion was normal, tonsil normal, no inflammatory secretions. Cardiopulmonary normal. Abdominal flat, liver and spleen not palpable, no tenderness of the four muscles, joint activity is normal. Clinical diagnosis: endemic typhus. real