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病历摘要 男,12岁。因口唇紫绀半年入院,患儿于半年前出现口唇紫绀,且进行性加重,活动后或遇寒冷紫绀明显,无胸闷、气急及心前区不适感,无蹲踞现象,无抽搐。当地医院诊断不明,转来我院。患儿于4年前曾患“血小板减少性紫癜”,已行“脾切除术”。否认肝炎、结核病接触史。体检:T37℃,P90次/min, R24次/min,体重13 kg。口唇紫绀,扁桃体Ⅱ°肿大,左侧颌下淋巴结约2cm×2 cm,双肺呼吸音清晰,心率96次/min、律整,各瓣膜听诊区未闻及明显病理性杂音,指(趾)呈杵状。实验室及其它检查:Hb170g/L,RBC5.8×10~(12)/L,WBC10.1×10~9/L,N0.68,L0.3,M0.02,HCT49.2％,PC215×10~9/L,BT1分钟,CT3分钟,尿、大便
Medical summary Male, 12 years old. Half a year due to lip cyanosis admission, children with cyanosis of the lips in six months ago, and progressive increase in activity or in case of cold cyanosis, no chest tightness, shortness of breath and precordial discomfort, no squat phenomenon, no convulsions. Local hospital diagnosis is unknown, transferred to our hospital. Children suffering from 4 years ago, “thrombocytopenic purpura”, has been “splenectomy.” Denied hepatitis, tuberculosis exposure history. Physical examination: T37 ℃, P90 times / min, R24 times / min, weight 13 kg. Lips cyanosis, tonsil Ⅱ ° enlargement, left submandibular lymph node about 2cm × 2cm, clear breath sounds in both lungs, heart rate 96 beats / min, law, the valve auscultation area was not known and obvious pathological murmur, ) Was clubbing. Laboratory and other tests: Hb170g / L, RBC5.8 × 10-12 / L, WBC10.1 × 10 ~ 9/L, N0.68, L0.3, M0.02, HCT49.2%, PC215 × 10 ~ 9 / L, BT1 minutes, CT3 minutes, urine, stool