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谢××,男,10岁,1972年11月13日入院。主诉:咽部异物感及吞咽困难4年。近半年来经常感冒,咽部疼痛,睡眠时有鼾声,不能平卧入睡。身体逐渐消瘦。近1月来慢步行走即感呼吸困难。只能吃进少量稀粥。检查:发育营养差,消瘦。表情淡漠,坐位呈轻度呼吸困难。发音含糊不清。全身皮肤干燥。双侧颌下淋巴结均肿大,能活动无压疼。中等度鸡胸。两肺有干鸣,心脏无异常。肝脾未触及。四肢活动好,关节不痛。耳、鼻未见异常。口咽腔:双侧扁桃上极绕过软腭进入鼻咽腔,下端伸进梨状窝,表面呈桑棋状,粘膜充血,陷窝口未见分泌物。舌腭弓、咽腭弓与扁桃体解剖标志不清,两侧扁桃体之间仅有0.3厘米间隙。舌扁桃体不肿大,腺样体大如花生。血液检查。血色素12.4克,红细胞400万,白细胞13,800,中性粒细胞74％、淋巴24％、单核2％、出
Xie × ×, male, 10 years old, admitted to hospital on November 13, 1972. Chief complaint: pharyngeal foreign body sensation and difficulty swallowing 4 years. Nearly six months often cold, pharyngeal pain, snoring sleep, can not lie to sleep. Body weight loss. Slow walking in the past January that breathing difficulties. Only eat a small amount of gruel. Check: Development of poor nutrition, weight loss. Indifferent expression, sitting was mild breathing difficulties. Pronunciation vague. Dry skin. Bilateral submandibular lymph nodes are swollen, can be activities without pressure pain. Medium chicken breast. Dry lungs both lungs, no abnormal heart. Liver and spleen not touched. Good limbs, joint pain. Ear, nose no abnormalities. Oropharyngeal cavity: bilateral almond pole around the soft palate into the nasopharyngeal cavity, the bottom into the pear-shaped nest, the surface was Chess like, mucosal hyperemia, no fossa nest socket secretions. Tongue palatal arch, pharyngeal palatal arch and tonsil dissection mark is unclear, only 0.3 cm gap between the sides of the tonsils. Tongue tonsils do not enlarge, adenoid as large as peanuts. blood test. 12.4 grams of hemoglobin, 3 million erythrocytes, 13,800 leukocytes, 74% neutrophils, 24% lymphoid, 2% mononuclear,