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病例摘要患者住院号11637,男性,20岁,因腹泻、呕吐、高热、烦躁不安,于1960年11月29日晚9时入院。缘于同年11月23日开始稀便,但次数不多。26日开始畏寒、发热、全腹痛、恶心、呕吐、腹泻,大便日达十余次,水样便,无脓血与里急后重,经服止泻剂无效,病情日益加重。29日下午体温达39.8℃,大便次数增多,日达20余次,大便失禁,恶心、呕吐加剧,呕出物为胃内容物。经一般处理扔无效,病人反而烦躁不安,神志不清,逐步进入半昏迷,口唇青紫,有脱水症,脉微细,有时摸不到。血压70/40毫米汞柱,有时测不清,急诊入院。既往无痢疾、肠阿米巴病及血吸虫病、肝胆病史。入院时检查:体温:39℃。脉搏:每分钟108次。呼吸每分钟28次。血压:70-95/40-50毫米汞
Case summary Patient hospitalization number 11637, male, 20 years old, was admitted to hospital at 9:00 on the November 29, 1960 due to diarrhea, vomiting, fever and irritability. Due to the same year began in November 23 loose stool, but a small number. On the 26th, chills, fever, full abdominal pain, nausea, vomiting, diarrhea, stool of more than ten times, watery stools, no sepsis and tenesmus, the service through the antidiarrheal agent is invalid, the condition is worsening. On the afternoon of the 29th, the body temperature reached 39.8 ° C. The number of stools increased, reaching more than 20 times a day. Fecal incontinence, nausea and vomiting intensified. The vomit was the stomach contents. After the general treatment throw invalid, the patient instead restless, unconscious, and gradually enter the semi-coma, lips bruising, dehydration, pulse fine, and sometimes touch. Blood pressure 70/40 mm Hg, sometimes undetectable, emergency admission. Past no diarrhea, intestinal amebiasis and schistosomiasis, history of hepatobiliary disease. Check on admission: body temperature: 39 ℃. Pulse: 108 beats per minute. Breathing 28 times per minute. Blood pressure: 70-95 / 40-50 mmHg