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病历摘要患者沈××,男性,24岁,上海市郊区农民。住院号37081。因休克后少尿1天于1975年3月20日入院。现病史;病人于入院前5天突感头昏,畏寒及发热,但当时未测体温,同时感觉全身酸痛及腰痛。第二天去赤脚医生处就诊,测体温为40.7℃,并出现腹痛、腹泻,每日约15次,水样便,带有少量粘液,但无里急后重,呕吐7~8次/日,非喷射性,为水样物。经口服氯霉素及肌注青霉素二天后热退,但全身酸痛及腰痛反见加重,并出现小便量减少。遂去当地县人民医院诊治,当时测血压0/0,以体克待查住院诊
Medical record summary Shen × ×, male, 24 years old, Shanghai suburban farmers. Hospital number 37081. One day after shock, oliguria was admitted on March 20, 1975. Current history; patients admitted to hospital 5 days suddenly felt dizzy, chills and fever, but did not test the body temperature at the same time feeling body aches and back pain. The next day to the barefoot doctor for treatment, measured body temperature was 40.7 ℃, and abdominal pain, diarrhea, about 15 times a day, watery stool, with a small amount of mucus, but no tenesmus, vomiting 7 to 8 times / day, non-jet Sexual, water samples. Chloramphenicol and intramuscular injection of penicillin two days after the heat back, but body aches and back pain aggravated, and decreased urine. Then go to the local county people’s hospital diagnosis and treatment, was measured blood pressure 0/0, in order to check the physical examination in hospital