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患男,16岁。因发冷、发热、头痛、乏力半月,加重伴寒战,四肢大关节及上腹部疼痛7d之主诉入院。查体:体温40℃、脉博140次/min、呼吸24次/min、血压12.5/9.0kPa,消瘦、神清,精神极差,急性重病容,贫血外貌,皮肤粘膜轻度黄染,浅表淋巴结不肿大。口腔粘膜轻度糜烂。双肺呼吸音粗糙,心尖区收缩期Ⅱ级吹风样杂音。肝区有叩击痛,肝剑下3cm,肋下1.5cm、边缘钝、有触痛。脾肋下3.5cm。腹稍膨隆、有压痛,无反跳痛及腹水。末梢血RBCO.67×10~(12)/L、Hb20g/L、WBC62×10~9/L,分类:杆状核、晚幼粒0.80、中幼粒0.12,原粒0.08。血小板52×10~9/L。肝功总胆红素24.8μmol/L,谷丙转氨酶950nmol/s。CO_2CP13.6mmol/L。B超肝脾
Male, 16 years old. Due to chills, fever, headache, fatigue half months, increased with chills, limbs and joints and upper abdominal pain 7d of the main admission. Examination: body temperature 40 ℃, pulse Bo 140 times / min, breathing 24 times / min, blood pressure 12.5 / 9.0kPa, weight loss, clear spirit, very poor spirit, acute serious illness, anemia, mild yellow skin mucosa, light Table lymph nodes are not enlarged. Oral mucosal mild erosion. Breathing sounds rough lungs, apical systolic grade Ⅱ hair-like murmur. Liver percussion pain, Liver Sword 3cm, ribs 1.5cm, blunt edge, tenderness. Spleen ribs 3.5cm. Abdomen slightly bulging, tenderness, no rebound pain and ascites. Peripheral blood RBCO.67 × 10 ~ (12) / L, Hb20g / L, WBC62 × 10 ~ 9 / L, classification: rod nucleus, late promyelocytic 0.80, progeny 0.12, the original particle 0.08. Platelets 52 × 10 ~ 9 / L. Liver total bilirubin 24.8μmol / L, alanine aminotransferase 950nmol / s. CO_2CP13.6mmol / L. B super liver and spleen