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张××,男,50岁,某粮库职工,住院号209552。因发热、咽痛、乏力一周后恶心、呕吐、排黑便,(约400～500g)于1984年11月6日入院。否认胃病史。入院时查体:体温36.5℃,血压测不出。皮肤潮红、无出血点。球结膜充血、出血、水肿,睑结膜明显充血。心肺未见异常。腹平软、肝脾未触及。化验:末梢血:白细胞81,100/mm~3,杆状39％,分叶46％,单核7％,早幼粒1％,中幼粒6％,晚幼粒1％。红细胞700万/mm~3,血红蛋白21g％,血小板5万/mm~3。便潜血+++。胸透:心肺未见异常。
Zhang × ×, male, 50 years old, a grain depot workers, hospital number 209552. Due to fever, sore throat, a week after fatigue, nausea, vomiting, Pai Meixian, (about 400 ~ 500g) was admitted on November 6, 1984. Denied stomach history. Admission examination: body temperature 36.5 ℃, blood pressure can not be measured. Skin flush, no bleeding point. Conjunctiva hyperemia, bleeding, edema, palpebral conjunctiva obvious congestion. Heart and lung no abnormalities. Abdomen soft, liver and spleen not touched. Assay: Peripheral blood: white blood cells 81,100 / mm ~ 3, 39% rod, 46% of leaves, mononuclear 7%, promyelocytic 1%, juvenile 6%, late juvenile 1%. 7 million red blood cells / mm ~ 3, hemoglobin 21g%, platelets 50,000 / mm ~ 3. Then occult blood +++. Chest throat: no abnormal heart and lungs.