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患者男,22岁,未婚,于1962年5月28日因发热七天,神志不清两天而入院. 现病史:一月来感全身乏力,食欲减退.近七天来轻度畏寒、发热,下午热更高,被迫卧床,且伴头痛,有时腹痛;26日晚起不认识亲人,胡言乱语,手乱抓,在公社医务所打退热针,用了青霉素,服中药三包,泻了二日. 既往及家族史:小时患过天花,平时身体健康,不饮酒.母亲死于呕血,父亲因跌倒后死亡. 体格检查:发育营养良好,重病容,神志不甚清楚,自己无意识地笑,手乱抓.腋下淋巴腺仅可
Patient Male, 22 years old, unmarried, admitted to hospital on May 28, 1962 for seven days due to fever, delirious for two days Present history of illness: I felt malaise and loss of appetite in January .In the past seven days, mild chills, fever, Afternoon hot higher, forced to bed, and with headache, and sometimes abdominal pain; on the evening of 26 do not know their loved ones, nonsense, hand grabbing, fight back in the commune medical hot needle, with penicillin, three bags of traditional Chinese medicine, Diarrhea on the 2nd. Past and family history: hours of smallpox, usually healthy, not drinking. The mother died of hematemesis, his father died after a fall. Physical examination: development of good nutrition, serious illness, consciousness is not clear, his unconscious Laughter, hands and scratching armpit lymphatic glands only