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病历摘要患者女,24岁,教师。主诉腹痛,鹿河伴发烧半月子1981年9月22日入院。诉16天前无明显诱因开始腹泻,先为黄色稀便,后为脓血粘液便,每日5～10次,体温38～39℃,排便前有较重之腹绞疼。先后诊为“肠炎”、“菌痫”,一般抗炎及输液治疗未效,进食即吐,且腹泻加重,呈洗肉水样,既往体健,无阳性家族病史。入院查体:体温38℃,血压140/90,脉搏100,呼吸22,发育正常、贫血貌,皮肤巩膜不黄染,表浅淋巴结不
Patient history Female, 24 years old, teacher. The main complaint of abdominal pain, Deer River with fever half moon on September 22, 1981 admission. No obvious incentive to tell 16 days before the onset of diarrhea, loose stools for the first yellow, followed by pus and blood mucus will be 5 to 10 times a day, body temperature 38 ~ 39 ℃, before defecation had abdominal pain. Has been diagnosed as “enteritis”, “bacterial epilepsy”, the general anti-inflammatory and infusion therapy fails, eating and vomiting, and diarrhea aggravated, was washed with water samples, previous health, no positive family history. Admission examination: body temperature 38 ℃, blood pressure 140/90, pulse 100, breathing 22, normal development, anemia appearance, skin sclera not yellow, superficial lymph nodes