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病历摘要患者男,33岁。于1990年10月5日以咳嗽、盗汗、胸闷、气短并低热1年余,肝功能异常5个月主诉入院。曾按结核治疗无效。1991年元月咯血1次,按支气管扩张治疗,2d 后咯血止,半月后咳嗽明显减轻。因仍低热,自觉乏力、纳差、腹胀,肝功能异常,乙肝病毒标志HB-Vm+,考虑乙肝后肝硬化由内科转传染科。查体:体温37.5℃,精神可,面色如常。巩膜无黄染。心肺无异常发现。肝肋下1.5cm,脾肋下2cm,腹水征(-)。实验室检查:RBC2.88×10~(12)/L,Hb84g/L,WBC5.6×10~9/L,N0.67。肝功能:ALT 正常,浊度试验明显异常,蛋白A/
Patient summary Male, 33 years old. On October 5, 1990 to cough, night sweats, chest tightness, shortness of breath and fever more than 1 year, liver function abnormalities were admitted for 5 months. Tuberculosis treatment has been invalid. January 1991 hemoptysis 1 times, according to bronchiectasis treatment, 2d hemoptysis, half a month after the cough significantly reduced. Due to still low fever, consciously fatigue, anorexia, abdominal distension, abnormal liver function, hepatitis B virus markers HB-Vm +, consider hepatitis B cirrhosis by internal medicine transfer dye department. Physical examination: body temperature 37.5 ℃, spirit can, look normal. Sclera without yellow dye. No abnormal heart and lung findings. Liver ribs 1.5cm, Spleen ribs 2cm, ascites sign (-). Laboratory tests: RBC2.88 × 10 ~ (12) /L, Hb84g / L, WBC5.6 × 10 ~ 9/L, N0.67. Liver function: normal ALT, turbidity test was abnormal, protein A /