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患者黄××,女性,21岁,住院号57,510。因进行性面色苍白、乏力半年,发热、心悸20多天,表情淡漠、间或乱语、视力模糊5天,经当地抗疟治疗无效于1984年3月4日入院。既往体健,否认有类似家族病者。体查:T38℃。慢性病容,贫血貌。表情淡漠,反应迟纯。右腋下及双腹股沟可触及数个0.8×0.6cm大小的淋巴结,无压痛,可活动。胸骨叩痛。心率124次,律整,未闻杂音。肝肋下2cm,质中。脾未及,未引出病理性神经反射。眼底:双侧视乳头雾状混浊、苍白、边界不清。中心凹消失。静脉弯曲充盈。黄斑消失。左眼颞侧及右眼鼻侧见多处片状出血斑。实验室检查:Hb7g,RBC260万,WBC25,700,分类:N73%,L17%,E10%,无幼稚细胞。PC 10.6万。嗜酸粒细胞计数6700。ESR70mm。尿蛋白++,红细胞0～1,白细胞0～3。大便未见寄生虫卵。黄疸常规
Patient Huang × ×, female, 21 years old, hospital number 57,510. Due to progressive pale, weak for six months, fever, heart palpitations more than 20 days, expression indifference, intermittent or disorderly, blurred vision 5 days, the local anti-malarial treatment invalid in 1984 March 4 admission. Past physical health, denied having similar family members. Physical examination: T38 ℃. Chronic disease, anemia appearance. Indifferent expression, the reaction is pure late. Right axilla and double groin can reach the number of 0.8 × 0.6cm size of the lymph nodes, no tenderness, can be active. Sternal sore neck. Heart rate 124 times, rhythm, no unheard noise. Liver ribs 2cm, quality. Spleen did not lead, did not lead to pathological reflex. Fundus: bilateral nipple fog cloudy, pale, the border is not clear. The foveal disappears. Vein bending filling. Macular disappears. Left eye temporal and right nasal see multiple flake bleed spot. Laboratory tests: Hb7g, RBC260 million, WBC25,700, classification: N73%, L17%, E10%, naive cells. PC 106,000. Eosinophil count 6700. ESR70mm. Urinary protein ++, 0 to 1 red blood cells, white blood cells 0 to 3. No parasite eggs in stool Jaundice routine