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患者27岁,住院号016375,患者3天前足月顺产一活女婴,产后发热,诊断产褥感染入院。查体:T38.4℃,Bp18/12kPa,贫血外貌,眼睑水肿,双锁骨上淋巴结肿大,双肺底中、小水泡音,心界扩大,Ⅱ级收缩期吹风样杂音,腹平坦,肝右肋下3.0cm,脾未触及,下肢水肿(+)。产科检查:会阴Ⅰ度裂伤,创口有脓性分泌物,子宫新生儿头大,压痛(+)。血常规:Hb50g/L,WBC4.6×10~9/L。导尿常规:WBC50～60个/HP,RBC5～10个/HP,上皮细胞:3～5个/HP,尿蛋白(++)。骨穿:感染骨髓并增生性贫血。CO_2CP16。
27-year-old patient, hospital number 016375, 3 days before the patient gave birth to a full-term baby girl, postpartum fever, diagnosis of puerperal infection admitted to hospital. Examination: T38.4 ℃, Bp18 / 12kPa, anemia appearance, eyelid edema, double supraclavicular lymph nodes, double bottom of the lung, small blisters sound, heart expansion, Ⅱ grade systolic hair-like murmurs, ventral flat, liver Right rib 3.0cm, spleen not touched, lower extremity edema (+). Obstetric examination: I perineal laceration, wound purulent secretions, uterine newborn head large, tenderness (+). Blood: Hb50g / L, WBC4.6 × 10 ~ 9 / L. Conventional catheterization: WBC 50 ~ 60 / HP, RBC 5 ~ 10 / HP, epithelial cells: 3 ~ 5 / HP, urinary protein (++). Bone wear: infection of bone marrow and hyperplastic anemia. CO_2CP16.