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例1 白×,男,18岁,战士,病案号104,135。因腹痛、腹泻20天,持续9天高热,于1973年1月25日由他院转入我科。患者于1973年1月初腹痛、腹胀、稀便,每天2～3次,胃纳差。1月16日发热,头晕。21日体温39.5～40.5℃,嗜睡,谵语。用土霉素、青,链霉素,未见效。23日用氯霉素,每天2g肌注,四环素每天1g静滴。24日下午体温骤降至35.5℃,脉搏88～90,血压90/60,面色苍白,大便失禁,遂送我院。检查:T35.5℃,P80,BP86/44,神志恍惚,谵语。皮肤轻度黄染,无皮疹。颈轻抵抗。双肺呼吸音粗糙,干性啰音?贡诮辖粽?轻压痛,肝肋下1cm,脾肋下2cm,质中等,克匿征可疑阳性。化验:血红蛋白8g,红细胞350万,白细胞3,700,
Example 1 White ×, male, 18 years old, soldiers, medical record number 104,135. Due to abdominal pain, diarrhea 20 days, sustained 9 days fever, on January 25, 1973 by his hospital into my department. Patients in early January 1973 abdominal pain, bloating, loose stools, 2 or 3 times a day, poor appetite. January 16 fever, dizziness. 21, body temperature 39.5 ~ 40.5 ℃, lethargy, sigh language. With oxytetracycline, green, streptomycin, no effect. 23 days with chloramphenicol, 2g intramuscular injection daily tetracycline 1g intravenous infusion. The temperature dropped to 35.5 ℃ on the afternoon of the 24th, pulse 88 ~ 90, blood pressure 90/60, pale, fecal incontinence, then sent to our hospital. Check: T35.5 ℃, P80, BP86 / 44, unconscious, brave language. Mild yellow skin, no rash. Neck light resistance. Lung respiratory sounds rough, dry rales? Gong 诮 Jurisdiction dumplings light tenderness, liver ribs 1cm, 2cm under the spleen ribs, medium quality, gram concealment sign suspicious positive. Laboratory: Hemoglobin 8g, 3.5 million red blood cells, white blood cells 3,700,