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1、MedicalRecordsforAdmissionMedicalNumber:701721GeneralinformationName:ChenXiangdiOccupation:StudentAge:SixteenMaritalstatus:NotmarriedSex:FemaleDateofadmission:8Am,July15th,2010Race:HanDateofrecord:10Am,June15th,2010Nationality:ChinaComplainerofhistory:Patient’sherselfAddr
2、ess:NO.61,GuannongRoad,HuangpuReliability:ReliableDistrict,Shanghai.Tel:******Chiefcomplaint:Fever,coughfortendays.Presentillness:Thepatientfelttiredwithfeveraftergettingwetinarain,thetemperaturewas38-39℃.Andsawdoctorinthelocalhospital.TheBRT:9WBC10.7*10/L,N72.9%,L23.1%.T
3、heconditiondidn’tgetbetteraftersymptomatictreatment.Thehighesttemperaturewas40℃.TheBRTonJulyth97showed:WBC7.8*10/L,N66.2%,L25.2%.ThepatientwasgivenRibavirin,0.5,qd;Cefuroxime,3.0,qd.Shestillhadhighfeveraftertreatment.Coughandexpectorationappeared.ThechestX-rayshowedthpneu
4、moniaintherightinferiorpart.TheBRTinRuijinHospitalonJuly119showed:WBC8.4*10/L,N58.5%,L23.1%,shewasgivensymptomatictreatmentofpyretolysisanddissipatephlegm,andstillhadfever.The9patientcametoourhospitalonJuly13.TheBRTshowedWBC8.98*10/L,N44.4%,L41.8%.ThechestX-rayshowedpneum
5、oniaintherightinferiorpart.ShewasgivenClindamycin1.2qd,Aztreonam2.0qdandstillhadfever.Thepatientdidn’thaddyspnea,tachypnea,chestpain,lowgradefever,nightsweat,diarrhea,abdominalpain,urinaryfrequency,urgentmicturition,urodynia,erythra,arthralgia.Shewasadmittedtoourhospitalf
6、orfurthertreatment.Generalstatusnormal.Spirit,sleep,appetitenormal.Stool,urinenormal.Noobviouschangeinweight.PasthistoryThepatientwashealthybefore.Nohistoryofinfectivediseases.Nohistoryofoperationortrauma.Nobloodtransfusionhistory.Noallergyhistoryofdrugs.PersonalhistorySh
7、ewasbornandlivedinShanghai.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.Nosmokinganddrinking.Noexposurehistorytoepidemicareaofinfectiousdiseases.Familyhistory:Herparentsarealiveandhealthy.PhysicalexaminationT38.1℃,P101/min,R20/min,BP110/70mmHg.Shewaswelldevel
8、opedandmoderatelynourished.Activeposition.Herconsciousnesswasclear.Herfacewaspaleandtheskinwasno