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患者、张××、女、24岁、工人、住院号991。左面部(?)肿,挤压后发烧四天,曾在个体中医诊所用中药外敷、口服螺旋霉素,肌注鱼腥草。因头痛、复视、乏力、全身不适、以败血症入院。体检:体温36℃、脉搏125次/分,呼吸18次/分,血压100/70mmHg。强迫半卧位、表情淡漠、痛苦面容,面色潮红。右上眼睑下垂、眼球突出,结膜充血。双肺呼吸音清,心率125次/分,心音低钝、律正、心界不大,右季助下叩击痛,腹平坦,肠音弱,全身肌力下降。
Patient, Zhang × ×, female, 24 years old, worker, hospital number 991. Left facial (?) Swollen, fever after squeezing four days, once in the individual Chinese medicine clinic with topical, oral spiramycin, muscle injection Houttuynia. Due to headaches, diplopia, fatigue, general malaise, sepsis admitted. Physical examination: body temperature 36 ℃, pulse 125 beats / min, breathing 18 beats / min, blood pressure 100 / 70mmHg. Forced semi-recumbent position, expression of indifference, painful face, looking flushing. Right upper eyelid ptosis, prominent eye, conjunctival hyperemia. Respiratory sound clear lungs, heart rate 125 beats / min, heart sound low blunt, law positive, little heart, the right quarter percussion pain, flat belly, weak intestinal sounds, decreased body muscle.