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患者男,29岁。因发热、头痛1周,用青、链霉素及对症治疗3天无效入院。T39.7℃,P84次/min, R18次/min, BP13/9kPa。双肺呼吸音稍粗糙。心率84次/min,心律规整。血常规、胸透等无异常,诊断为上呼吸道感染。给青链霉素及对症支持疗法,但体温持续在39℃左右。入院次日出现体温脉搏分离现象,右眼结合膜出现两个小出血点。胸片示左肋隔角变钝。腹部叩诊鼓音。肝右肋下2cm,质软、触痛,脾左肋下3cm, ALT200U,加用抗病毒中药治疗无效。
Patient male, 29 years old. Due to fever, headache 1 week, with blue, streptomycin and symptomatic treatment 3 days invalid admission. T39.7 ° C, P84 times / min, R18 times / min, BP13 / 9kPa. Breath sounds slightly rough lungs. Heart rate 84 beats / min, heart rhythm. Blood, chest and other no abnormalities, the diagnosis of upper respiratory tract infection. To penicillin and symptomatic supportive therapy, but the body temperature continued at about 39 ℃. The second day after admission, there was a phenomenon of body temperature pulse separation, there were two small bleeding spots in the right eye conjunctiva. Chest radiograph showed left atrial septum blunt. Abdomen percussion drum sound. Liver right rib 2cm, soft, tender, spleen left rib 3cm, ALT200U, plus anti-viral Chinese medicine treatment is invalid.