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1996年4月20日死亡病历讨论纪要 主任 今日进行死亡病历讨论,请实习医师报告病历。 实习医师 患者,男,40岁,河北省某县农民。患者于10天前无明显诱因地突然发烧达40℃伴头痛、乏力。当地医师发现球结膜黄染,有少量腹水以重症肝炎转入我科。入院时检查一般情况差,皮肤、球结膜黄染明显,腹股沟淋巴结肿大1.5×1.5cm质较硬,无压痛。全身其余淋巴结未扪及。心、肺未发现异常。腹较膨隆,肝大肋下4cm,脾大肋下3.5cm,无压痛。移动性浊音(+),下肢无浮肿。
The summary of the death record on April 20, 1996, was discussed by the director of the death medical record today, and an internship doctor is required to report the medical record. Intern Practitioner Patient, male, 40 years old, farmer in a county in Hebei Province. The patient had a sudden fever of 40°C without headaches and fatigue for 10 days before. Local doctors found that the conjunctiva was yellow and a small amount of ascites was transferred to our department with severe hepatitis. On admission, the examination was generally poor. The skin and bulbar conjunctiva stained yellow, and the inguinal lymphadenopathy was 1.5×1.5 cm hard and no tenderness. The rest of the body’s lymph nodes were not affected. No abnormalities were found in the heart and lungs. Abdominal bulging, liver ribs 4cm, splenomegaly ribs 3.5cm, no tenderness. Mobile dullness (+), no edema in the lower extremities.