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病史摘要患者男性,24岁,中山医院住院号×××××。因腹水7个月于1977年12月1日入院。患者于同年4月开始上腹胀痛、纳差,间有烧心、嗳酸,一个月后出现腹水,伴明显乏力。外院诊断为“肝硬化腹水”,经中西医治疗3个月,腹水曾消退,停药后腹水又渐增多。曾疑及结核性腹膜炎而于9月起试以抗痨治疗(异烟肼0.6克/天,链霉素1.0克/天)共29天,无效,且日益消瘦,不伴发热和黄疸。12月1日黑便一次,血压下降至60～70/?毫米汞柱,急诊入院。既往体健。否认疫水接触史,偶吸烟及饮酒。体检:慢性病容。巩膜无黄染,无肝掌。颈部见蜘蛛痣,颈静脉无怒张,锁骨上淋巴结未扪及。胸廓对称;心肺听诊阴性。腹水明显,隐约可见腹壁静脉;腹软,无压痛,无反眺痛;肝脾触诊不清,未及痞块。下肢不肿。辅助检查:红细胞585万/立方毫米,血红蛋白18克％;
Summary of patient history Male, 24 years old, hospital Zhongshan Hospital No. ×××××. Due to ascites 7 months in December 1, 1977 admission. Patients in the same year in April began abdominal pain, anorexia, between heartburn, 嗳 acid, one month after ascites, with significant fatigue. Outside the hospital diagnosed as “cirrhosis of the liver”, after three months of treatment of Chinese and Western medicine, ascites has subsided, after stopping ascites and gradually increased. Suspected tuberculous peritonitis in September and tried anti-tuberculosis treatment (isoniazid 0.6 g / day, streptomycin 1.0 g / day) a total of 29 days, ineffective, and increasingly weight loss, without fever and jaundice. December 1 stool, blood pressure dropped to 60 ~ 70 /? Mm Hg, emergency admission. Past physical health. Denied the history of exposure to water, even smoking and drinking. Physical examination: Chronic disease. Sclera no yellow dye, no liver palm. See spider nevus neck, neck vein without rage, supraclavicular lymph nodes palpable. Thorax symmetry; cardiopulmonary auscultation negative. Obvious ascites, vaguely visible abdominal wall veins; soft belly, no tenderness, no objectionable pain; liver palpation palpation unclear, and the lump of the abdomen. Lower extremity not swollen. Auxiliary examination: red blood cells 5850000 / cubic mm, hemoglobin 18g%;