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患者李某,女16岁,住院号3—198。以四肢困痛、全身散在性皮肤紫斑5日为主诉入我院内科。查体:T36℃,P78次/分,R20次/分,BP12/8kPa。神志清楚,精神欠佳,痛苦面容。躯干及双上肢散在性大小不等紫色皮疹,双下肢呈对称性大小形态不同的皮肤紫斑,压之不退色,压痛(+),双下肢轻度肿胀,活动时稍感疼痛。心肺未见明显异常。腹平软,脐周压痛(+)。反跳痛(-),肝脾未扪及,肠鸣音正常。神经系统未见异常。查血:RBC3.4×10~(12)/L,Hb105g/L,WBC16×10~9/L,N0.87,L0.11%,BT 3′,CT2′PC273×10~9/L~(12)/L,诊断:过敏性紫癜(重度)。
Patient Lee, aged 16, hospital number 3-198. Pain in the limbs, the whole body scattered purpura on the 5th main complaint into our hospital. Physical examination: T36 ℃, P78 times / min, R20 times / min, BP12 / 8kPa. Conscious, unsympathetic, painful face. Trunk and upper extremities scattered in the size of the purple rash, symmetrical size of the lower extremity of the skin purple spots, pressure of non-fading, tenderness (+), mild swelling of both lower extremities, slightly painful activity. Heart and lung no obvious abnormalities. Abdomen soft, umbilical tenderness (+). Rebound pain (-), liver and spleen not palpable, normal bowel sounds. Nervous system no abnormalities. Check the blood: RBC3.4 × 10-12 / L, Hb105g / L, WBC16 × 10 ~ 9/L, N0.87, L0.11%, BT3 ’, CT2’PC273 × 10 ~ 9 / L ~ (12) / L, diagnosis: Henoch-Schonlein purpura (severe).