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龙某某,男,47岁,农民。住院号:830076。因头项强痛一月余,于1983年1月16日抬送入院。患者于1982年12月初,因感寒后始觉恶寒发热,汗出,头痛,咳嗽,在本公社卫生院按感冒治疗4天,寒热、咳嗽等症消失,而头痛不减,以枕部为甚,并见颈项强直,时有烧灼感而转送某县人民医院,经治疗1周未效而转来我院。询知既往无头颈部外伤史,入院时症见头痛以枕部为甚,颈项强直,不可俯仰,不能转侧,伴畏寒、纳差、神疲、汗出、尿少。诊视病人神清,颈项强直,双眉紧锁,呻吟不已,伸舌偏向右侧,舌尖边淡紫、苔黑腻而润滑,脉细数无力。查:血常规,Hb10.8%,WBC14800/mm~3,N88%,
Long Mou, male, 47 years old, farmer. Hospital number: 830076. Due to the first day of severe pain, he was admitted to the hospital on January 16, 1983. In early December 1982, the patient developed chills, fever, sweat, headache, and cough after suffering a cold. He was treated with a cold for 4 days in the hospital of the communes. His fever, cough, etc. disappeared, and headaches remained unchanged. In fact, I saw neck stiffness, which caused a burning sensation and was transferred to a county people’s hospital. After a week of treatment, it was not effective and was transferred to our hospital. Inquired about the past history of head and neck trauma, admitted to hospital when the disease see the headache to the occipital, the neck stiffness, can not be pitched, can not turn side, with chills, anorexia, Shenpi, sweating, urine. The patient was diagnosed with a clear vision, the neck was stiff, the eyebrows were tight, and his eyes were closed. The tongue leaned toward the right side, the pale edge of the tongue was pale, the moss was greasy and smooth, and the pulse was weak. Check: Blood routine, Hb 10.8%, WBC14800/mm~3, N88%,