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患者男性,19岁,船工,住院号156237,因持续发热1月、腹泻1周于1990．5.16以发热待查入院。住院前1月曾在江中游泳并饮大量生水,两天后畏寒、发热、乏力、头昏,服退热药无效,发热日渐加重,体温39.5~40℃,外院查血象正常,服药后无好转。入院前一周出现腹泻,黄色水样便,2~5次/日,无粘液脓血及里急后重。查体:体温40．2℃,脉搏104次/分,呼吸25次/分,血压16.2/9.8kPa,神志清楚,表情淡漠,轻度贫血貌,无皮疹,出血点及伤口,巩膜不黄,浅表淋巴结不大。心肺无特殊发现,腹平软,肝肋下5cm,质软,边锐,有叩击痛,脾未及。
Male patient, 19 years old, ship worker, hospital number 156237, due to persistent fever in January, 1 week of diarrhea in 1990.5.16 with fever to be admitted to hospital. One month before hospitalization, he was swallowing in the river and had plenty of raw water. After two days, chills, fever, weakness, dizziness and fever were ineffective and the fever increased. The body temperature was 39.5-40 ℃. No improvement. A week before admission, diarrhea, yellow watery stools, 2 to 5 times / day, no mucus and pus and tenesmus. Examination: body temperature 40.2 ℃, pulse 104 beats / min, breathing 25 beats / min, blood pressure 16.2 / 9.8kPa, conscious, apathy, mild anemia, no rash, bleeding and wounds, sclera is not yellow, Superficial lymph nodes are not. Heart and lung no special findings, abdominal soft, liver ribs 5cm, soft, sharp edge, percussion pain, spleen and time.