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患者男,59岁。因乏力1个月余,于2012年3月2日入院。患者1个多月前无明显诱因感全身乏力,稍活动后即感双下肢酸软、气短难续,无其他不适。体检:T 38.5℃,BP 121/81 mmHg,R 20次/min,P 92次/min。贫血、消瘦貌,皮肤、巩膜轻度黄染,全身皮肤黏膜无淤点、淤斑,浅表淋巴结未及。胸骨无压痛,双肺呼吸音粗,右下肺可闻及少许湿性罗音。腹部、双肾检查无异常,双下肢无浮肿。神经系统检查无异常。血常规:WBC 2.8×109/L,N 63.4%,RBC 1.16
Male patient, 59 years old. Due to fatigue for more than 1 month, on March 2, 2012 admission. More than 1 month before the patient had no obvious incentive to feel malaise. After a little activity, he felt both lower extremities soreness and shortness of breath, with no other discomfort. Physical examination: T 38.5 ° C, BP 121/81 mmHg, R 20 cycles / min, P 92 cycles / min. Anemia, thin appearance, skin, scleral mild yellow dye, systemic skin and mucous membrane without cramps, ecchymosis, superficial lymph nodes. No tenderness of the sternum, lung breath sounds thick, right lower lung can smell a little wet rales. Abdominal, kidney examination no abnormalities, no swelling of both lower extremities. No abnormal neurological examination. Blood: WBC 2.8 × 109 / L, N 63.4%, RBC 1.16