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病历摘要患者贺××,男,20岁,战士,湖南籍。1963年7月5日入院。主诉:发烧、头痛、肚痛已六天。缘6月29日下午,突然感到畏寒,全身不适及头痛。卫生员给复方安基匹林3片,分三次服。第二天上午无特殊感觉,仍能坚持工作。下午又感到头痛、四肢无力。卫生员检查体温38℃,仍内服退热片。第三天上午检查时,体温正常,但仍有头痛。可以进食,无恶心嘔吐。但下午头痛加重,并伴有腹部持续性疼痛及腹胀腹泻,大便稀,色黄,无脓血。卫生员给复方樟脑酊内服,腹痛可暂时缓解,腹泻停止。第四天仍有头痛腹痛,不思饭食。卫生员检查体温不高,停服退热片,下午又发烧达39℃。
Patient summary He × ×, male, 20 years old, soldier, Hunan nationality. July 5, 1963 admitted to hospital. Chief complaint: fever, headache, abdominal pain has been six days. Edge June 29 afternoon, suddenly felt chills, malaise and headache. Health workers to compound 3 aspirin, in three servings. No special feeling the next morning, still able to work. Afternoon felt a headache, weakness. Health examiner body temperature 38 ℃, still taking oral antipyretic tablets. The third day morning check, the body temperature is normal, but there are still headaches. Can eat, no nausea and vomiting. However, the headache worsened in the afternoon and accompanied by persistent abdominal pain and abdominal distension and diarrhea, loose stools, yellowish color and no abscessed blood. Health workers give compound camphor tincture orally, abdominal pain can be temporarily alleviated, diarrhea stopped. The fourth day is still headache abdominal pain, do not think meals. Hygienists check the body temperature is not high, stop taking antipyretic tablets, fever in the afternoon up to 39 ℃.