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沈×,男,45岁,工人,住院号801128。于1980年10月3日因腹胀、尿少伴胸闷一月而入院。患者近3月来反复腹胀、尿少,伴两下肢浮肿而多次住当地医院治疗。近一月来腹胀明显,伴胸闷、呼吸急促而由当地医院转来我院。检查:体温37℃,脉搏96次/分,呼吸26次/分,体重53公斤。10年前曾患过传染性肝炎。慢性病容,神志清,皮肤巩膜不黄,五官无异常,甲状腺不大。气管略左偏。颈部可见数颗蜘蛛痣。两侧胸廓无畸形,右侧胸腔积液体征。心脏未见异常。腹膨,腹壁静脉充盈,腹水征明显。肝肋下未及。脾肋下5厘米。血
Shen ×, male, 45 years old, worker, hospital number 801128. On October 3, 1980 due to abdominal distension, oliguria with chest tightness in January and admission. Patients with repeated bloating in recent 3 months, oliguria, accompanied by lower extremity edema and repeatedly live in the local hospital for treatment. Obvious bloating over the past month, with chest tightness, shortness of breath and transferred from the local hospital to our hospital. Check: body temperature 37 ℃, pulse 96 beats / min, breathing 26 beats / min, weight 53 kg. He had had infectious hepatitis 10 years ago. Chronic disease, delirious, sclera skin is not yellow, facial features are normal, thyroid is not large. Trachea slightly left deviation. Several spider nevus visible in the neck. No abnormality of the thorax on both sides of the right pleural effusion signs. No abnormal heart. Abdominal swelling, abdominal wall filling, marked ascites sign. Liver under the ribs. Spleen rib 5 cm. blood