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病历摘要郭××,男,17岁。反复酱油色尿一个月,伴黑便、恶心、呕吐,加重五天入院。于入院前40天无何诱因发现咽痛、全身不适,自服索密痛数片;10天后因劳累出现酱油色尿,尤以晚上及早晨起明显,伴右侧头痛,左半身麻木,偶有短暂四肢抽搐伴乏力、头晕、牙龈出血、柏油便,1日2～3次。曾在当地医院诊断为感冒,经青、链霉素肌注3天无好转近5天来上述症状加重,活动后心悸、气短;恶心、呕吐胃内容物。病后无高热、腰痛及尿路刺激等症状。1岁时曾患小儿麻痹。平素健康,否认结核、肝炎等病史,家族中无类似疾病者。
Medical records Guo × ×, male, 17 years old. Repeated soy sauce color urine a month, with black, nausea, vomiting, increased five days admitted to hospital. 40 days before admission without any incentives found sore throat, general malaise, self-Suochitong several painful; 10 days due to fatigue appear soy sauce urine, especially in the evening and morning obviously with the right headache, left half numbness, even Have a short limb twitch with fatigue, dizziness, bleeding gums, ashes, on the 1st 2 to 3 times. Had a local hospital diagnosis of a cold, green, streptomycin intramuscular injection 3 days no improvement for nearly 5 days to the above symptoms, palpitations, shortness of breath after activity; nausea, vomiting stomach contents. No fever after the illness, back pain and urinary tract irritation and other symptoms. 1 year old had polio. Usually healthy, denied tuberculosis, hepatitis and other medical history, no similar family disease.