【正文】
er of History): 主訴(Chief Complaint): headache and fever for 10 days.現(xiàn)病史(History of the Present Illness):10 days ago, the patient had headache for no obvious reasons. There was persistent pain on the external parietal part of the head. The pain was not related to postural changes. The trigger was unclear but was acpanied by fever with body temperature fluctuations between 176。 fructose injection” to decrease the intracranial pressure. Furthermore, PPI was given to decrease the stomach pain and rehydration treatment was done but, there was no significant improvement in the symptoms. The patient then came to the emergency room of our hospital where he was diagnosed as having “intracranial infection” and was admitted to the hospital. Upon admission, the patient’s mind was clear, the spirit was good, he had a poor appetite, his sleep was good, he had soft yellow stool and there was no significant change in weight. 29 years ago, the patient had a renal history of tuberculosis.住院病歷(二)(Medical Records for Admission) 既往史(Past Medical history):General health status: normalComorbid conditions: Hypertension: Absent Cardiac disease: Absent Diabetes mellitus: Absent Kidney disease: AbsentHistory of infectious diseases:Tuberculosis: Absent Hepatitis: AbsentOthers: 29 years ago, he had a renal history of tuberculosis.History of preventive inoculation: Inoculation plan pleted.Allergic History: History of blood transfusion: Negative: Negative History of scars/wounds: Negative: Negative History of surgical operations: Negative :