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1病历摘要例1:女,31岁。因咽部不适、声嘶0.5h立即就诊。1h前因面部红斑、丘疹伴瘙痒3d来我科就诊,诊断为皮炎。给予咪唑斯汀10mg口服,未服用其他药物。服药后20min即感咽部不适,无心悸气紧,立即来我科就诊。体检:一般情况良好,R21次/min,唇无发绀,面部、四肢、躯干未见皮损。咽部检查:咽部无充血、水肿,双侧扁桃体Ⅰ度大。耳鼻喉科会诊喉镜检查:会厌、劈裂无充血水肿,双侧声带水肿,轻充血,闭合稍差,运动好。梨状窝无积液,声门下无异常。
1 Medical Summary Example 1: Female, 31 years old. Due to throat discomfort, hoarseness 0.5h immediate treatment. 1h ago due to facial erythema, papules and itching 3d to our clinic, diagnosed as dermatitis. Mizolastine given 10mg orally, did not take other drugs. 20min after taking medicine that throat discomfort, no heart palpitations gas tight, immediately to our department. Physical examination: generally good, R21 times / min, lip cyanosis, facial, limbs, trunk no skin lesions. Pharyngeal examination: throat no congestion, edema, bilateral tonsil Ⅰ degree. Otorhinolaryngology consultation laryngoscopy: Epiglottic, splitting without congestion and edema, bilateral vocal cord edema, light congestion, closing slightly worse, good exercise. Pi Li Wo no effusion, no abnormal subglottic.