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病史摘要患者男,38岁,上海川沙县人,农民,住院号115544。患者于1980年9月16日起感发热、乏力,但无寒战。曾住某卫生院,测肥达氏反应(-),血白细胞2600,中性64％,淋巴36％,血小板64000,血沉4mm/h,尿蛋白(++),白细胞(0～1),偶见颗粒管型。曾用青、庆大霉素及激素治疗6天,体温持续在39～40℃,伴咳嗽,偶混有鲜红色血丝。感腹胀,食欲明显减退。于9月23日转来本院。
Summary of patient history Male, 38 years old, Chuan Sha County, Shanghai, peasant, hospital number 115544. From September 16, 1980, the patient developed fever and fatigue, but no chills. Once lived in a hospital, measuring fat Dahre’s reaction (-), white blood cells 2600, 64% neutral, lymphatic 36%, platelets 64000, erythrocyte sedimentation rate 4mm / h, Occasionally granular tube type. Had green, gentamicin and hormone therapy for 6 days, body temperature continued at 39 ~ 40 ℃, with cough, even with a bright red bloodshot eyes. Sense of bloating, loss of appetite significantly. Transferred to our hospital on September 23.