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病历摘要郑××,男,40岁,建筑工人,住院号308,086。因寒战、高热10天,无尿2天于1983年10月13日入院,缘患者于10天前出现发热,伴畏寒及寒战,体温持续于39～39.5℃,无出汗。伴全身不适,精神疲乏,间有烦躁。经大剂量青霉素和红霉素等治疗,仍高热不退。第三天发现血压下降(80/50),即在加强抗生素治疗基础上用多巴胺、阿拉明等药作升压处理,血压基本能以维持,但病情日甚。于转入本院前2天,突然无尿,尿量每日不足100ml。相继出现精神呆滞、恶心、呕吐,1次呕出咖啡色胃内容物约500ml、曾解大便1次,便质正常。近半月来皮肤患有多处(疒节)肿,未作特殊处理,既往史无特殊。体检:T37.8℃,R46次,P120次,BP80/50。神志朦胧,皮肤无皮疹,巩膜无黄染。头面五官无特殊,颈软,淋巴结无肿大,心律整,心率120次,第一心音减弱,各心瓣膜区无杂音。双肺有散在湿啰音?刮⒄?有弥漫性压痛,无包块,肝肋下1cm,边锐无压痛,脾未扪及,叩诊无移动性浊音,肠鸣音减弱。双侧
Medical record summary Zheng × ×, male, 40 years old, construction workers, hospital number 308,086. Due to chills, fever 10 days, anuria 2 days in October 13, 1983 admitted to the edge of patients in 10 days ago fever, with chills and chills, body temperature continued at 39 ~ 39.5 ℃, no sweating. With general malaise, mental fatigue, irritability. The high-dose penicillin and erythromycin and other treatment, still high fever. The third day found that blood pressure decreased (80/50), that is, in the strengthening of antibiotic treatment based on the use of dopamine, Alamin and other drugs for treatment of blood pressure, blood pressure can basically maintain, but the disease is growing. 2 days before the transfer to our hospital, suddenly no urine, urine output less than 100ml daily. Have mental retardation, nausea, vomiting, vomit brown stomach content of about 500ml, once stool 1, normal quality. Nearly half of the skin has multiple (nodules) swollen, not for special treatment, no previous history. Physical examination: T37.8 ℃, R46 times, P120 times, BP80 / 50. Obscure mind, skin rash, sclera no yellow dye. No special facial features, neck soft, no lymph node enlargement, heart rhythm, heart rate 120 times, the first heart sound weakened, the heart valve area without noise. There are scattered lung wet rales? Scrapping? There are diffuse tenderness, no mass, liver ribs 1cm, while sharp no tenderness, the spleen is not palpable, percussion no moving dullness, bowel sounds weakened. Bilateral