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支某,男,54岁。因发热3天,腹泻1天于1980年8月5日入院。患者于3天前开始畏冷发热。体温稽留在39℃左右。入院前一天开始腹泻,初为稀水便、量多、无粪质。于腹泻4次后转为大便失禁。曾呕吐两次,吐出物为胃内容。腹泻后感心慌,无气喘。既往体健,无心慌、心前区不适病史。体检:体温39.7℃,脉搏110次,呼吸22次,血压70/50毫米汞柱。急性病容,神志恍惚,反应迟钝。全身皮肤干燥。眼眶凹陷,口唇呈樱红色,心界不大,心率120次,心律完全不规则,心音强弱不一,各瓣膜区未闻病理性杂音。脉搏短绌。呼吸深大,两肺正常。腹软,左下腹略压疼,肝脾未触及,肠鸣音稍亢进,余无异常发现。
Support a, male, 54 years old. Due to fever for 3 days, diarrhea 1 day in August 5, 1980 admission. Patients started chills and fever three days ago. Body temperature left at about 39 ℃. The day before admission began diarrhea, early watery stool, amount, no fecal material. After diarrhea 4 times into fecal incontinence. Have vomited twice, vomit for the stomach content. Fear after diarrhea, no asthma. Past physical health, no panic, precordial discomfort history. Physical examination: body temperature 39.7 ℃, pulse 110 times, breathing 22 times, blood pressure 70/50 mm Hg. Acute illness, trance, unresponsive. Dry skin. Orbital depression, lips were reddish, little heart, heart rate 120 times, the heart rhythm is completely irregular heart sounds vary, the valve area is not heard pathological murmur. Short pulse. Breathing, both lungs normal. Abdominal soft, slightly lower left abdominal pain, liver and spleen not touched, bowel sounds a little hyperthyroidism, I found no abnormalities.