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患者,女,66岁.1989年5月无明显诱因发热4天,伴头昏、乏力、咽喉疼痛.门诊胸透示“双肺纹理增强、紊乱,未见实质性病变”.以“发热待查”入院.体检:T 38.4℃,P 84次/分,R 20次/分,Bp14.7/9.3 kPa.贫血貌,神志清晰,全身皮肤粘膜无瘀斑瘀点,无黄染.浅表淋巴结不肿大,咽部充血,双侧扁桃体Ⅲ°肿大,牙龈无红肿,胸骨中下段压痛明显,心肺无异常发现,肝肋下刚触及,脾助下5cm,中等硬度.B超提示“慢性胆囊炎、胆囊结石”.
Patient, female, 66 years old. In May 1989, there was no obvious cause of fever for 4 days, with dizziness, fatigue, and sore throat. Outpatient Chest showed “double lung texture enhancement, disorder, no substantial lesions.” Check “admitted to hospital. Physical examination: T 38.4°C, P 84 beats/min, R 20 beats/min, Bp 14.7/9.3 kPa. Anemic appearance, conscious mind, body skin and mucous membranes, no yellow spots. Lymph nodes are not swollen, pharyngeal hyperemia, bilateral tonsil enlargement, no swelling in the gums, tenderness in the middle and lower sternal bone, no abnormalities found in the heart and lungs, liver subcostal just touched, the spleen to help the next 5cm, medium hardness. B ultrasound tips Chronic cholecystitis, gallstones."