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病历摘要患者男性,43岁,农民。因发热、腰痛12日,不能行走伴尿潴留5日,于1989年6月3日入院。查体:温39.2℃,血压14.7/9.3kPa,急性高热病容,呼吸急促,全身皮肤未见出血点及疖肿,浅表淋巴结不肿大,双侧外耳道无脓性分泌物,副鼻窦无压痛,扁桃体不肿大。肺呼吸音粗糙,未闻及湿性罗音,心率128次/分,腹部膨隆,胀气,无压痛及反跳痛,肝脾肋缘下未触及,腹部叩诊鼓音,肠鸣音消失,腰3.4椎体叩击痛。颅神经(一),双下肢肌张力低,腱反射弱,肌力Ⅰ级,未引出病理反射,胸8平面以下皮肤针刺痛觉减退。尿潴留,颈轻度抵抗。实验室检查:
Medical record Summary Male patient, 43 years old, farmer. Due to fever, back pain on the 12th, can not walk with urinary retention on the 5th, on June 3, 1989 admission. Physical examination: temperature 39.2 ℃, blood pressure 14.7 / 9.3kPa, acute high fever, shortness of breath, no bleeding and swollen body skin, superficial lymph nodes are not enlarged, bilateral purulent purulent secretion, paranasal sinuses without tenderness , Tonsil does not enlarge. Lung breath sounds rough, unobstructed and wet rales, heart rate 128 beats / min, abdominal bulging, flatulence, no tenderness and rebound tenderness, liver and spleen under the edge of the ribs did not touch, abdominal percussion drum sounds, bowel sounds disappear, waist 3.4 Vertebral percussion pain. Cranial nerves (a), low muscle tension in both lower extremities, weak tendon reflexes, muscle strength I, did not lead to pathological reflex, chest acupuncture under the 8 plane acupuncture hypoparathyroidism. Urinary retention, neck mild resistance. Laboratory examination: