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患者翟××,女性,63岁,因右季肋部针刺样疼痛伴发烧20天,当地医院经抗炎、止痛、镇静治疗效果不佳,全身情况日差,于1986年4月12日入院(病案号57910)。查体:T38～39.5℃,P120次/分,BP14.7/8.0kPa(110/60mmHg),呈发热痛苦病容,全身衰竭明显、右季肋部轻度水肿,6～8肋间有明显压痛及叩击痛,肝于肋缘下约4cm,质中等硬度,触痛明显。腹平软,脾未触及。实验室检查:白细胞78～88.8×10~9/L(78000～88800/mm~3),中性粒细胞88～93%,可见中毒颗粒, 血红蛋白105g/L(10.5g%),黄疸指数7单位,GPT100单位以下,尿三胆正常,乙型肝炎病毒表面抗原
Patient 翟××, female, 63 years old, with acupuncture-like pain in the right quarter of the ribs with fever for 20 days. The local hospital was poorly treated by anti-inflammatory, analgesic, and sedative treatments. The general condition was poor on April 12, 1986. Admission to hospital (Case No. 57910). Physical examination: T38～39.5°C, P120 beats/min, BP14.7/8.0kPa(110/60mmHg), fever and pain, severe systemic failure, mild edema in the right quarter flank, marked tenderness in 6～8 intercostal space As well as percussive pain, the liver is approximately 4 cm below the costal margin and is of moderate hardness and tenderness. The abdomen is soft and the spleen is not touched. Laboratory examination: WBC 78-88.8×10-9/L (78000～88800/mm~3), neutrophils 88～93%, visible toxic particles, hemoglobin 105g/L (10.5g%), jaundice index 7 Unit, below GPT100 units, normal urine gall bladder, hepatitis B virus surface antigen