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患者;宁某,男,66岁。以发热,咳嗽,腹胀,乏力加重5个月。1年前患者因低热,咳嗽,左上腹胀痛,鼻血,发现全血减少,异常淋巴细胞出现。而诊断为门静脉高压症。 入院检体:T38.2℃,P 88次BP15/9kPa。神志清,贫血貌,全身皮肤粘膜未见出血点,巩膜无黄染。浅表淋巴结不大。心肺无异常。腹胀,左上腹部高度隆起,无胸腹壁静脉怒张,肝大肋缘下2.5cm,质软。脾肿大明显,占腹腔面积约3/4,光滑,可动性不良。 化验:Hb 85g/L,RBC3.0×10~(12)/L WBC11.2×
Patients; Ning, male, 66 years old. To fever, cough, bloating, fatigue aggravate 5 months. A year ago because of fever, cough, left upper quadrant pain, nosebleed, found that whole blood decreased, abnormal lymphocytes. The diagnosis of portal hypertension. Admission samples: T38.2 ℃, P88 BP15 / 9kPa. Consciousness, anemia appearance, systemic skin and mucous membrane no bleeding, sclera no yellow dye. Superficial lymph nodes are not. No abnormal heart and lung. Abdominal distension, left upper abdomen height bulge, chest wall abdomen veins, liver big costal margin 2.5cm, soft. Splenomegaly obvious, accounting for about 3/4 of the abdominal area, smooth, poor mobility. Assay: Hb 85g / L, RBC3.0 × 10-12 / L WBC11.2 ×