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病历摘要男性患者,30岁,农民,于1992年5月24日入院。6d前因施洒农药出现持续畏寒发热,呈弛张热,次日发现尿黄,如浓茶样,无恶心、呕吐,无腹痛,腹泻及腹胀,当地医院予以肌注青、链霉素等治疗3d,效果不佳,病后3d出现鼻衄,全身皮肤粘膜黄染,并呈进行性加重转入我院。病后食欲正常,每日食量400～450g。1992年3月初曾因发热10d,鼻衄1次在西安市第二职工医院住院,经应用激素等治疗,体温正常出院。体格检查:体温39℃,呼吸30/min,血压16/10.7kPa。轻度贫血貌,全身皮肤、巩膜中度黄染,浅表淋巴结不肿大,两鼻腔渗血不止,胸骨无压痛,左肺底可闻及少许湿啰音,心率1059/min,律齐,各瓣膜未闻及病理性杂音,腹软,肝上界位于右锁
Medical summary Male patient, 30 years old, farmer, was admitted on May 24, 1992. 6d before the sprinkle of pesticides due to persistent chills and fever, was heat of relaxation, the next day found that urine yellow, such as strong tea-like, no nausea, vomiting, no abdominal pain, diarrhea and bloating, the local hospital to intramuscular injection of streptomycin And other treatment 3d, poor results, the disease appeared after 3 days epistaxis, systemic skin and mucous membrane yellow dye, and was progressive increased into our hospital. Normal appetite after illness, daily appetite 400 ~ 450g. In early March 1992 due to fever 10d, epistaxis 1 second hospital in Xi’an hospital, the application of hormones and other treatment, the normal temperature was discharged. Physical examination: body temperature 39 ℃, breathing 30 / min, blood pressure 16 / 10.7kPa. Mild anemia appearance, body skin, sclera moderate yellow dye, superficial lymph nodes does not enlarge, more than two nasal bleeding, sternum no tenderness, left lung bottom can be heard and a little wet rales, heart rate 1059 / min, The valve is not known and pathological murmur, abdominal soft, upper liver is located in the right lock