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病史摘要:夏某,男,19岁,学生,住院号7284。因畏寒发热20天,在乡村医院使用洁霉素、氯霉素、庆大霉素,地塞米松、复方新诺明等药物治疗20天,体温不退。近三天来出现头痛,恶心、呕吐。于1988年9月11日转我院治疗。体检:体温37.8℃,脉搏92次,呼吸32次,血压130/80mmHg。神志清楚,巩膜无黄染,两肺呼吸音粗,未闻及干湿性罗音,心率92次,律齐,未闻及病理性杂音。腹软,肝肋下2cm,质地中等,无压痛,脾肋下2cm,质地软,腹部无移动性浊音。神经系统检查;颈项强直,克氏征及布氏征均阳性。
Summary of medical history: Xia Mou, male, 19 years old, student, hospital number 7284. Because of chills and fever for 20 days, in rural hospitals using lincomycin, chloramphenicol, gentamicin, dexamethasone, cotrimoxazole and other drugs for 20 days, body temperature is not retreat. Headache, nausea and vomiting in the past three days. On September 11, 1988 to our hospital for treatment. Physical examination: body temperature 37.8 ℃, pulse 92 times, breathing 32 times, blood pressure 130 / 80mmHg. Consciousness, Sclera no yellow dye, two lungs breathing tone coarse, unheard-of wet and dry rales, heart rate 92 times, law Qi, no smell and pathological murmur. Abdominal soft, liver ribs 2cm, medium texture, no tenderness, Spleen ribs 2cm, soft texture, no movement of the abdomen dullness. Neurological examination; neck stiffness, Kirschner sign and Clint’s sign were positive.