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病历摘要 吴某,男,19岁,未婚,农民。因腹痛、腹泻两个月,发热、黑便4月入院。两个月前无明显诱因出现上腹隐痛,时隐时现,伴有腹泻,粪呈黄色糊状,无腥臭味,每日2～3次,未诊治。入院前4日腹痛阵发加剧,解成形黑便2次。当晚发热达40℃,经补液、降温治疗无缓解。此后3日连续解黑便。于1986年6月27日来我院急诊,T39℃,BP13.3/9.33kPa(100/70mmHg),Hb30g/L,WBC4×10~9/L,N0.7,L0.3。次日以上消化道出血、发热原因待查收入院。既往史无特殊。
Medical summary Wu, male, 19 years old, single, peasant. Due to abdominal pain, diarrhea two months, fever, black will be admitted in April. Two months ago there was no obvious incentive for upper extremity pain, when the hidden, with diarrhea, dung, yellow paste, no fishy smell, 2 to 3 times a day, no diagnosis and treatment. 4 days before admission abdominal pain burst exacerbated, black forming solution 2 times. Fever up to 40 ℃ that night, after rehydration, cooling treatment without remission. After 3 consecutive black solution. In June 27, 1986 to our hospital emergency room, T39 ℃, BP13.3 / 9.33kPa (100 / 70mmHg), Hb30g / L, WBC4 × 10 ~ 9 / L, N0.7, L0.3. Gastrointestinal bleeding the next day, the cause of fever to be admitted to hospital. No previous history.