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患者李××,男,55岁,工人。主因发热、腹泻、腹痛3天,加重1天,于1982年5月18日15时入院。入院前三天无诱因发热、腹泻、腹疼、休克,急送我院门诊以中毒性痢疾收住院。一年前曾有肝硬化门脉高压上消化道出血史。入院检查:体温39℃,脉搏138次/分,呼吸40次/分,血压80/60mmHg,神志呈嗜睡状态,四肢发凉,全身可见散在的蜘蛛痣及出血点,肝掌,心肺未见异常,腹膨隆,肝不大,脾肋下3～4cm,质硬,腹水征(+),肠鸣音较弱,无肌卫及腹膜刺激
Patient Lee × ×, male, 55 years old, worker. Mainly due to fever, diarrhea, abdominal pain for 3 days, increased 1 day, at 15:00 on May 18, 1982 admitted. Three days before admission, no incentives for fever, diarrhea, abdominal pain, shock, emergency hospital sent to our hospital for toxic dysentery. A year ago had cirrhosis of the upper gastrointestinal bleeding history. Admission examination: body temperature 39 ℃, pulse 138 beats / min, breathing 40 beats / min, blood pressure 80 / 60mmHg, drowsiness state of mind, limbs cold, the body visible spider nevus and bleeding, palms, heart and lung no abnormalities , Abdominal bulging, liver is not large, 3 ~ 4cm spleen ribs, hard, signs of ascites (+), bowel sounds weaker, no muscle and peritoneal stimulation