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一九八三年六月二十五日上午第一次查房主治医师:请实习医师汇报病史。实习医师甲:患儿男,3岁,因持续发热、乏力一个月,于85年6月7日入院。患儿予入院前一个月,惊吓后开始嗜睡,持续发热,体温39℃左右,伴有乏力,及肉眼血尿,黑便两次。2～3天后血尿黑便消失,仍有发热、乏力。但无头痛、呕吐、腰痛及黄疸、皮肤出血点等。曾先后在院外应用青霉素、红霉素及氨苄青霉素等治疗,病情无好转而来我院。平素有盗汗,结核病密切接触史。体检:体温38℃、脉搏120次/分,血压90/50mmHg,发育正常,消瘦,呼吸平稳,皮肤粘膜
First round of physicians check in on the morning of June 25, 1983 Attending physician: Ask the intern to report on the medical history. Intern a: male patient, 3 years old, due to persistent fever, fatigue for one month, on June 7, 85 admission. Children admitted to hospital one month before starting scared to lethargy, sustained fever, body temperature 39 ℃, accompanied by fatigue, and gross hematuria, black then twice. 2 to 3 days after the disappearance of hematuria black, there are still fever, fatigue. But no headache, vomiting, back pain and jaundice, skin bleeding and so on. Has worked in the hospital outside the penicillin, erythromycin and ampicillin and other treatment, no improvement in our hospital. Usually have night sweats, tuberculosis close contact history. Physical examination: body temperature 38 ℃, pulse 120 beats / min, blood pressure 90 / 50mmHg, normal development, weight loss, stable breathing, skin and mucous membranes