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第一次查房(1988年6月3日) 主治医师:请实习医师报告病史。实习医师:患者女,32岁。1988年6月2日以“肝硬化,肝性脑病”收入消化科。1年前无诱因出现头晕乏力,发烧、全身皮肤间歇性出现紫瘢而住某院检查治疗。当时检查发现肝脾肿大,贫血、血小板减少,而诊为“肝硬化,血小板减少性紫瘢”,给予输血及对症治疗,症状稍好转出院。出院后上述症状经常复发,未经特殊处理。半月前因受凉,出现纳差、乏力、厌油、恶心,但无呕吐,也未诊治。近6天来出现畏寒
First rounds (June 3, 1988) attending physician: ask the intern to report the medical history. Intern: Female patient, 32 years old. June 2, 1988 to “cirrhosis, hepatic encephalopathy” income digestion section. 1 year ago, no incentive to dizziness and fatigue, fever, intermittent purple scar skin and live in a hospital check treatment. At that time examination found hepatosplenomegaly, anemia, thrombocytopenia, and diagnosed as “cirrhosis, thrombocytopenic purpura”, giving blood transfusion and symptomatic treatment, the symptoms were slightly better discharged. The above symptoms often recur after discharge, without special treatment. Half a month ago due to cold, appear anorexia, fatigue, tired of oil, nausea, but no vomiting, nor diagnosis and treatment. Nearly 6 days have chills