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病历摘要患者男性,33岁。入院前5天感畏寒,发热、头痛、伴持续性上腹部胀痛及脐周闷痛,腹泻稀便7～8次/日。2天后到某医院诊治,T40℃,经肌注热可平,口服中药后高热、腹泻不见减轻,遂来院就诊。体检:T39.1℃,P104次/分,R22次/分,BP80/50mmHg。腹部略饱满,脐周有轻压痛,无反跳痛。肝肋下2cm,质软有轻压痛,脾(-)。畅鸣音减弱。实验室检查:Hb10.5g,WBC
Summary of patient history Male, 33 years old. 5 days before admission, chills, fever, headache, with persistent upper abdominal pain and umbilical pain, diarrhea loose stool 7 to 8 times / day. After 2 days to a hospital for treatment, T40 ℃, intramuscular injection of heat can be flat, oral administration of traditional Chinese medicine after high fever, diarrhea, no reduction, then came to the hospital. Physical examination: T39.1 ℃, P104 times / min, R22 times / min, BP80 / 50mmHg. Abdomen slightly full, mild tenderness around the umbilical cord, no rebound tenderness. Liver ribs 2cm, soft and mild tenderness, spleen (-). The pause of the sound is weakened. Laboratory tests: Hb10.5g, WBC