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病历摘要患者男性,29岁,腹痛五个月,发热、脓血便一月余入院。患者于5个月前出现上腹部胀痛不适,疼痛为灼热样,伴泛酸、暧气,无恶心、呕吐,未经治疗,数日后自行缓解。一月前出现脐周间歇性隐痛伴腹泻,每日二至三次,为脓血便,无里急后重感,曾用“痢特灵”、“阿托品”等治疗,腹泻未缓解。入院一月后起出现畏寒、发热,体温波动在38～39℃,出汗多,无咳嗽、胸痛。曾解血便100ml,伴头昏,全身出汗。在某医院给予止血、补液,并输血1000ml。此后每日大便二次,呈暗紫色或果酱色,量较多,体温仍波动在38～39℃之间。既往史无
Summary of medical records Male patients, 29 years old, abdominal pain for five months, fever, pus and blood will be admitted to hospital for more than a month. The patient had upper abdominal pain and discomfort 5 months ago. The pain was a hot type, accompanied by pantothenic acid, warm gas, no nausea and vomiting. After untreated, the patient relieved a few days later. A month ago appeared intermittent umbilical cord with diarrhea diarrhea, two to three times a day for the purulent blood, no tenesmus, had “furazolidone”, “atropine” and other treatment, diarrhea did not ease. From January after admission chills, fever, body temperature fluctuations in the 38 ~ 39 ℃, sweating, no cough, chest pain. Have to understand bloody stool 100ml, with dizziness, sweating. In a hospital to give bleeding, rehydration, and blood transfusion 1000ml. Since then, the second day of the stool, dark purple or jam color, the amount of more body temperature is still fluctuating between 38 ~ 39 ℃. Past history