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1991年6日19日查房纪要——主治医师请主管病人的医师报告病历。住院医师男患,4岁,于1991年6月16日入院,患儿于2个月前开始发热,呈间歇发热,热时自觉头痛,不吐泻,无腹痛,多汗,时有关节疼痛,并见出皮疹1次,起病初体温达38.4℃,伴抽风3次,每次历时10分钟即缓解,此后间断发热,未吐,精神食欲尚可,在当地医院住院3天,热退出院,后又发热,当地以“感冒”治疗,体温时高对低持续已1月,50天前曾来我院门诊检查,肝在剑突下4cm,肋
June 19, 1991 rounds summary - the attending physician in charge of the patient’s physician report the medical record. Resident Male patient, 4 years old, admitted to hospital on June 16, 1991, the patient started fever 2 months ago, was intermittent fever, headache when hot, no vomiting, no abdominal pain, sweating, when the joint pain, And saw a rash 1, the onset of early body temperature reached 38.4 ℃, with convulsions 3 times, each time lasted 10 minutes to ease, then intermittent fever, no spit, the spirit of appetite is acceptable in the local hospital for 3 days, retreat from the hospital , And then fever, the local “cold” treatment, when the body temperature high and low sustained in January, 50 days ago to our hospital clinic, the liver in the xiphoid 4cm, ribs