Present histol On examination( this hospital ). PE: T:38.0°C;P:107;BP:126/68mmHg; R:20 An ulcer at the hairline eft cervical lymphadenopathy with firm, tender, mobile nodes was present heard at the right upper sternal A systolic murmur (grade 2 /6)w Clinical Photographs border Specimens of blood and urine were sent for culture. Normal saline and broad-spectrum antibiotics were administered intravenously
2 Present history : On examination（this hospital）： PE: T: 38.0°C; P:107; BP:126/68 mm Hg; R:20 An ulcer at the hairline Left cervical lymphadenopathy with Pirm, tender, mobile nodes was present. A systolic murmur (grade 2/6) was heard at the right upper sternal border. Specimens of blood and urine were sent for culture .Normal saline and broad-spectrum an6bio6cs were administered intravenously. Clinical Photographs
3 Personal history She had a remote history of a cesarean section she had no known allergies She lived with her husband and dog and was a homemaker During the 2 months before the onset of illness, she had been living in a wooded area of coastal New England; she took frequent walks to ponds and to the beach, kayaked, and had seen deer skunks, and rabbits Several months before the onset of illness, she had taken a hiking trip in southern California Consumed alcohol in moderation, did not smoke or use illicit drugs, and had no exposure to sick persons A sister had systemic lupus erythematosus, and other family members had hypertension, cataracts, and glaucoma
3 Personal history : She had a remote history of a cesarean section she had no known allergies She lived with her husband and dog and was a homemaker. During the 2 months before the onset of illness, she had been living in a wooded area of coastal New England; she took frequent walks to ponds and to the beach, kayaked, and had seen deer, skunks, and rabbits. Several months before the onset of illness, she had taken a hiking trip in southern California Consumed alcohol in moderation, did not smoke or use illicit drugs, and had no exposure to sick persons. A sister had systemic lupus erythematosus, and other family members had hypertension, cataracts, and glaucoma
4 Laboratory Data Other Hospital, Other Hospital, Reference Range, 5 Days before 2 Days before Other Hospital, This Hospital, Variable Adults? Admission Admission Day of Admission on Admission Hematocrit (9) 36.0-46.0 38(ref37-47) 31.9 Hemoglobin(g/dl) 120-16.013.1(ref12.0-160) 13.5 12.3 11.0 White-cell count(per mm) 4500-1100011600(ref4500 5100 7400 7100 11,000) ifferential count(%) Neutrophils 40-70 87(ref28-62) 72.3 Lymphocytes 22-44 6(ref21-49) 9.5 Monocytes 4-11 7(ref2-10) 17.5 Basophils 0-3 1(ref0-2) 0.3 Platelet count(per mm) 150000-400,000289000(ref 173,000 225.000 180.000 150.000-450.000) Sodium(mmol/ liter) 135-145 130(ref133-145) 128 Potassium(mmol/ liter) 3.4-4.8 3.6(ref3.3-5.1) 3.6 3.2 Chloride(mmol /liter) 100-108 91(ref96-108) Carbon dioxide(mmol/ liter) 23.0-31.9 26(ref22-31) Phosphorus(mg/dl) 2.6-4.5 2.2 mucose(mg/dl) 70-110 122(ref70-10 127 127 Alanine aminotransferase(U/liter) 15(ref-33) 104 163 Aspartate aminotransferase(U/ liter) 9-32 15ref10-35) 120 Alkaline phosphatase(U/liter) 30-100 69(ref35-104) 108 Amylase(U/liter 68(ref28-100)
4 Laboratory Data