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患者男性,41岁。因发热19d伴黑便1次于1992年4月28日第1次入院。患者不明原因发热,体温39～41℃,午后上升,晨起热退,伴盛汗。热前无寒战,病程中无其他伴随症状。高热时用激素可暂时缓解。入院当日解柏油样便1次。查体:T39.1℃,P96次/min,R14次/min,Bp14/8kPa。急性热病容,皮肤无黄染、皮疹及结节,表浅淋巴结不大,心肺听诊无异常。腹软肝肋下2cm。脾肋下4cm,质硬无触痛。关节无红肿,肌肉无压痛。神经系统检查无异常。实验室检查:血WBC2.3×10~9/L,中性0.59,淋巴0.41,嗜酸细胞计数0。ERS35mm/h。肝功正常。大便潜血强阳性。入院诊断:伤寒并发肠出血。
Male patient, 41 years old. Due to fever 19d with black one times in April 28, 1992 the first admission. Patients with unexplained fever, body temperature 39 ~ 41 ℃, rising in the afternoon, hot morning retreat, with sweat. No chills before fever, no other symptoms during the course of the disease. Hyperthermia with hormones can temporarily ease. On the day of admission will be a solution like asphalt. Physical examination: T39.1 ℃, P96 times / min, R14 times / min, Bp14 / 8kPa. Acute fever, no yellow skin, rashes and nodules, superficial lymph nodes, cardiopulmonary auscultation no abnormalities. Abdominal soft liver ribs 2cm. Spleen ribs 4cm, hard no tenderness. Joints without swelling, muscle tenderness. No abnormal neurological examination. Laboratory tests: blood WBC2.3 × 10 ~ 9 / L, neutral 0.59, lymph 0.41, eosinophil count 0. ERS35mm / h. Normal liver function. Fecal occult strong positive. Admission diagnosis: typhoid complicated with intestinal bleeding.