【摘 要】
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患者女性,59岁,因"鼻塞、言语含糊五月,口干二月,乏力一月"人院.患者五月前起无明显诱因出现鼻塞,无脓涕、血涕,嗅觉无明显异常,并有言语含糊,声音变粗;2011-11无锡市第二人民医院五官科拟诊为鼻窦炎、慢性咽炎、会咽炎收住院,查Hb114g/l;Cr49.6umol/l;肝功能:白蛋白32.5g/l,球蛋白56.8g/l;住院期间行功能性鼻内窥镜手术,术中见鼻腔狭窄、鼻中隔后段右侧偏曲,双侧中
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患者女性,59岁,因"鼻塞、言语含糊五月,口干二月,乏力一月"人院.患者五月前起无明显诱因出现鼻塞,无脓涕、血涕,嗅觉无明显异常,并有言语含糊,声音变粗;2011-11无锡市第二人民医院五官科拟诊为鼻窦炎、慢性咽炎、会咽炎收住院,查Hb114g/l;Cr49.6umol/l;肝功能:白蛋白32.5g/l,球蛋白56.8g/l;住院期间行功能性鼻内窥镜手术,术中见鼻腔狭窄、鼻中隔后段右侧偏曲,双侧中鼻甲息肉样变,术后诊断为"慢性鼻窦炎、鼻中隔弯曲、急性会咽炎、慢性喉炎",术后予抗过敏治疗;近二月来出现口干,舌无苔,烦渴喜饮,眼干涩,反复口腔溃疡;近一月出现乏力;病程中,患者无反复发热,小腿有少许瘀斑瘀点,无关节肿痛,无咳嗽咳痰、咯血、胸闷气喘,无血尿、泡沫尿、浮肿,无腹痛、腹泻,无肢体乏力、感觉异常;2013-02-08我科门诊查:血常规:WBC 5.3×109/L,N 59.8％,Hb 77g/L,PLT 168×109/L;CRP 4mg/L,ESR 140mm/h;肝功能:ALB 19.1g/L,GLB 80.9g/L;肾功能:Cr 155umol/L;RF94.4IU/ml;ANA1:80阳性,抗ENA多肽:抗SSA弱阳性,抗SSB弱阳性,抗U1RNP弱阳性;抗dsDNA 160IU/ml;入院查体:T36.7℃,P 70次份,Bp 130/86mmHg,轻度贫血 貌,小腿皮肤可及少许瘀斑瘀点,舌左缘、右侧颊粘膜见点状溃疡,舌无苔,舌体胖,伸舌无偏斜,颈部扪及多个黄豆大小淋巴结,质中,无压痛,活动度可,呼吸平,两肺呼吸音清,无干湿啰音,HR 70次/分,律齐,未及病理杂音,全腹软,无压痛、反跳痛,肝脾肋下未及,双下肢无浮肿,各关节S-T-.
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