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病历摘要例一:病例20926,男性,18岁,山西汾阳人中学生,1959年5月7日下午10时入院。家人代诉:发冷发烧头痛咳(口敕),右侧胸痛已三天。三天前,劳动后受凉,头痛头晕全身无力,食欲不振,发冷发烧,服中药无效。昨日呕吐一次,呈黄绿色液体,咳(口敕)吐铁锈色痰,右侧胸痛,口干口苦,口鼻周围有泡疹。继而头痛加剧,神智模糊,说胡话不睁眼急诊来院。检查:体温39C(腋下),脉搏100次/分,发育正常营养中等,急性衰竭病容,神智蒙眬不断谵语,
Case summary: Case 20926, male, 18 years old, middle school student in Fuyang, Shanxi, admitted to hospital on May 7, 1959 at 10:00. Family complaints: chills, fever, headaches, coughs (mouthache), right chest pain for three days. Three days ago, I suffered from cold after work, headache, dizziness, general weakness, loss of appetite, chills and fever, and ineffectiveness in taking Chinese medicine. She vomited once a day and was a yellowish-green liquid. He had coughing sputum, sputum rust, right chest pain, dry mouth, and a blistering rash around his mouth and nose. Then headaches intensified, the mind was ambiguous, and nonsense came to the hospital. Check: body temperature 39C (armpit), pulse rate 100 beats/minute, moderate normal developmental nutrition, acute depletion, delirium