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患者,男,36岁。1979年10月因纳差,乏力,在某医院查肝功能:黄胆指数14u,SGPT240u,诊断为“急性黄疸型肝炎”,经休息及一般保肝治疗两个月后症状消失,肝功能正常。一年后肝功能反复异常,曾先后3次在院治疗。12天前因牙龈自发性出血,双下肢散在淤点,头昏,尿黄,再次入院。既往无血液病及药物过敏史。 体检:T37.2℃,P130次,BP120/70。慢性病容,重度贫血貌。面部及颈部可见数枚蜘蛛痣。巩膜中度黄染;口腔粘膜可见散在出血点,双大腿内侧皮肤散在淤点淤斑,压之不退色。浅表淋巴结不肿大。心率130次,律齐,心尖区可闻Ⅱ级吹风样收缩期杂音。两肺(一)。肝肋缘下1.0cm,剑突下1.5cm,质中,表面光滑,轻度压痛。脾肋下2.0cm。腹水征可疑。双下肢轻度浮肿。
Patient, male, 36 years old. October 1979 due to anorexia, fatigue, check liver function in a hospital: scrotal index 14u, SGPT240u, diagnosed as “acute jaundice hepatitis”, after rest and general liver treatment two months after the symptoms disappeared, normal liver function . One year after repeated abnormal liver function, has 3 times in hospital treatment. 12 days ago due to spontaneous bleeding gums, both lower extremities scattered in the deposition, dizziness, urine yellow, re-admitted. No previous history of blood disease and drug allergy. Physical examination: T37.2 ℃, P130 times, BP120 / 70. Chronic disease, severe anemia appearance. Several spider moles can be seen on the face and neck. Sclera moderate yellow dye; oral mucosa visible scattered bleeding point, double thighs inside the skin scattered spots ecchymosis, the pressure does not fade. Superficial lymph nodes are not enlarged. Heart rate 130 times, law Qi, apical area can be heard Ⅱ grade hair-style systolic murmur. Two lungs (a). Under the liver margin of 1.0cm, xiphoid 1.5cm, quality, smooth surface, mild tenderness. Spleen ribs 2.0cm. Ascites sign suspicious. Lower extremity mild edema.