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患者王××,女,32岁,因发热两月余.于1978年11月4日住院.患者于2个月前开始发热,腹胀,纳差,右下腹有时隐痛,大小便正常,平素身体健康。体检:体温38℃,脉搏82次/分,呼吸22次/分,血压100/70毫米汞柱.发育正常,营养尚可,神志清楚,呈慢性病容,皮肤无黄染、皮疹及出血点,体表淋巴结不肿大,心肺(一),腹软、平坦,右侧中下腹轻度压痛,肝于右肋下3厘米处可触及,质软,平滑,轻压痛,脾不大.化验检查:血常规:血红蛋白11克%,红细胞359万,白细胞9200,中性70%,淋巴28%,单核2%.尿常规,蛋白(一),脓球(+).
Patients Wang × ×, female, 32 years old, due to fever more than two months in November 4, 1978 hospitalized patients in 2 months ago fever, bloating, anorexia, right lower quadrant sometimes dull pain, normal urine, normal body health. Physical examination: body temperature 38 ℃, pulse 82 beats / min, breathing 22 beats / min, blood pressure 100/70 mmHg. Normal development, nutrition is acceptable, conscious, chronic disease, skin yellow dye, rash and bleeding, Body surface lymph nodes are not enlarged, heart and lung (a), abdominal soft, flat, right lower abdomen mild tenderness, the liver in the right rib 3 cm can be touched, soft, smooth, mild tenderness, spleen is not. Blood: hemoglobin 11 g%, erythrocyte 3590000, white blood cells 9200, neutral 70%, lymphatic 28%, mononuclear 2% .Normal, protein (a), pus ball (+).