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患者男性,19岁。因发热、呕吐、腹泻三天入院。既往无心、肾疾病史。查体:T37℃,P96次/分,R24次/分,BP12/7KPa。神志清,精神差。全身皮肤粘膜未见出血点,球结膜充血水肿不明显。口唇无紫绀。颈软,无抵抗。心率96次/分,律齐,心音强,未闻及早搏和杂音。两肺呼吸音清晰。腹平软,肝脾助下未触及,全腹有不固定压痛,双侧肾区叩击痛阳性。实验室检查:Hb133g/L,WBC27.2×10~9/L,N0.88,L0.12,BFC89×10~9/L,BT2′,CT3′,尿蛋白2+,BUN13.43mmol/L,Cre290.1mmol/L,K~+5.7mmol/L,Na~+136mmol/l,Cl~-86mmol/L,Ca~(2+)1.35mmol/L,CO_2CP14.1mmol/L。出血热特异性IgM抗体强阳性。临床诊断:流行性出血热
Male patient, 19 years old. Due to fever, vomiting, diarrhea three days admitted. Past no reason, a history of kidney disease. Physical examination: T37 ℃, P96 beats / min, R24 beats / min, BP12 / 7KPa. Conscious, poor spirit. No skin mucosa bleeding, conjunctival hyperemia edema is not obvious. No cyanosis lips. Soft neck, no resistance. Heart rate 96 beats / min, Law Qi, strong heart sound, no premature beat and noise. Breath sounds clear both lungs. Abdomen soft, liver and spleen to help not touched, the whole abdomen has not fixed tenderness, bilateral renal percussion pain positive. Laboratory tests: Hb133g / L, WBC27.2 × 10 ~ 9 / L, N0.88, L0.12, BFC89 × 10 ~ 9 / L, BT2 ’, CT3’, urinary protein 2 +, BUN13.43mmol / L , Cre290.1mmol / L, K ~ + 5.7mmol / L, Na ~ + 136mmol / l, Cl ~ -86mmol / L, Ca 2+ 1.35mmol / L and CO_2CP14.1mmol / L. Hemorrhagic fever-specific IgM antibodies are strongly positive. Clinical diagnosis: epidemic hemorrhagic fever