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病例摘要例1:住院号64—4171,周××,女性,16岁,因头昏、畏寒、发热半小时于1964年7月13日下午3时半入院。患者于当日下午精神不掁,无食欲,3时左右,突然头昏、畏寒发热、呕吐四次,内容为食物。9时许,连续水样大便,有红白脨,约每小时三—四次,量不多,有里急后重、持续高热,无腹痛。发病前身体健康,无受凉及不洁饮食史。入院检查:体温40.5℃,脉率130次/分,呼吸28次/分、血压100/60毫米汞柱,发育及营养中等,急性病容,
Case Summary Example 1: Hospitalization Number 64-4171, Week XX, Female, 16 years old, admitted to hospital due to dizziness, chills and fever for half an hour at 13:30 on July 13, 1964. Patients in the afternoon on the spirit of restless, no appetite, about 3 o’clock, suddenly dizzy, chills and fever, vomiting four times, the content of food. 9 o’clock, continuous watery stool, red and white 脨, about three or four times per hour, the amount is small, a tenesmus, sustained high fever, no abdominal pain. Before the onset of good health, no cold and unclean diet history. Admission examination: body temperature 40.5 ℃, pulse rate 130 beats / min, breathing 28 beats / min, blood pressure 100/60 mm Hg, development and nutrition is moderate, acute disease,