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患者男,64岁,椒江市大陈镇双加村人,因畏寒发热、头痛、腰痛伴纳减、恶心、呕吐3天,于1988年5月31日入院。体检发现;T39.3℃,P96,R20,Bp106/64mmHg,神志清,急性病容,洒醉貌,巩膜无黄染,球结膜充血水肿,上腭及胸部有散在出血点,颈软,心肺听诊无异常,腹平软、无压痛,肝、脾肋下未及,两侧肾区有明显叩击痛,病理反射阴性。B超提示肾实质损害,尿蛋白++,血Wbc 11000/μl,N72%,L25%,M3%,找到异型淋巴细胞,出血热抗体1:20阳性,入院第4天第二份血清抗体
Male, 64, of Dachang Village, Dachen Town, Jiaojiang City, was admitted to the hospital on May 31, 1988 for three days because of chills and fever, headache and back pain with nausea and vomiting. Physical examination found; T39.3 ℃, P96, R20, Bp106 / 64mmHg, clear consciousness, acute disease, drunk appearance, scleral no yellow dye, conjunctival congestion and edema, palate and chest scattered blood spot, soft neck, cardiopulmonary auscultation No abnormalities, abdominal soft, no tenderness, liver, spleen and ribs did not reach the both sides of the kidney area has obvious percussion pain, pathological reflex negative. B ultrasound prompted renal parenchymal damage, urinary protein ++, blood Wbc 11000 / μl, N72%, L25%, M3%, found atypical lymphocytes, haemorrhagic fever antibody 1:20 positive, admitted to the hospital on the 4th day of the second serum antibody