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病历摘要初诊患者,男性,32岁,发热半天来诊。发热前有受凉史,体温最高39.6℃,伴有畏寒、乏力,无寒战,咽痛明显,无流涕、咳嗽、咳痰等其他症状。既往体健,无发热患者接触史。查体无皮疹,可见结膜充血,咽红,双侧扁桃体!。大,散在少许白苔,心、肺、腹查体无异常。实验室检查:血常规提示白细胞计数(WBC)12.6×109/L,中性粒细胞百分数(NE)84%,血红蛋白·(Hb)、血小板(PLT)正常。初步考虑患者为上呼吸道感染,给予阿莫西林口服,同时予解热镇痛药和中成药对症处理。
Medical history Abstract Newly diagnosed patients, male, 32 years old, fever for half a day visit. Chilling history before fever, body temperature 39.6 ℃ maximum, with chills, fatigue, chills, sore throat clear, no runny nose, cough, sputum and other symptoms. Previous physical health, no history of exposure to fever in patients. Examination without rash, visible conjunctival congestion, throat, bilateral tonsils! Large, scattered in a little white moss, heart, lung, abdominal examination no abnormalities. Laboratory tests: blood routine prompted a white blood cell count (WBC) 12.6 × 109 / L, neutrophil percentage (NE) 84%, hemoglobin (Hb), platelet (PLT) normal. Initial consideration of patients with upper respiratory tract infection, given amoxicillin oral, antipyretic analgesics and proprietary Chinese medicines symptomatic treatment.