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患者,男,60岁。因头晕乏力、心慌半年,加重伴低热、上腹部疼痛及咳嗽2个月,当地医院拟诊“贫血、肺炎、肝癌”治疗无效,于1991年10月15日收入院。查体:T 37℃,P 90次/分,R 18次/分,BP20/12kPa。贫血貌,皮肤粘膜无出血点及瘀斑。浅表淋巴结无肿大。头颅无畸形,颅骨无缺损。胸骨无压痛。心律齐,未闻及杂音。双肺呼吸音粗,右下肺可闻及小水泡音。腹平软,肝上界于右锁骨中线第6肋间,肝下界肋下5cm,质软,表面光滑,无触痛。脾肋下3cm,表面光滑,无触痛。辅助检查:Hb 52 g/L,RBC1.17×10~2/L,WBC 17×10~9/L,N 0.16,L 0.19,浆细胞0.65,PC 45×10~9/L。ESR 165mm/h,肝功能正常,HBsAg阴性,血浆蛋白T 129g/L,A 15g/L,G 114g/L。蛋白电泳:A
Patient, male, 60 years old. Due to dizziness, fatigue, flustered for six months, aggravated with fever, upper abdominal pain and cough for 2 months, the local hospital to be diagnosed “anemia, pneumonia, liver cancer” treatment ineffective, in October 15, 1991 income hospital. Examination: T 37 ℃, P 90 beats / min, R 18 beats / min, BP20 / 12kPa. Anemia appearance, skin and mucous membrane without bleeding and ecchymosis. Superficial lymph nodes without swelling. No deformity of skull, no defect of skull. Sternal no tenderness. Qi heart Qi, no smell and noise. Breath sounds coarse lungs, right lower lungs can smell small blisters and sound. Abdomen soft, the upper bound of the liver in the right intercostal midline 6th intercostal space, 5cm ribs under the liver, soft, smooth surface, no tenderness. Spleen rib 3cm, smooth surface, no tenderness. Auxiliary examination: Hb 52 g / L, RBC1.17 × 10 ~ 2 / L, WBC 17 × 10 ~ 9 / L, N 0.16, L 0.19, plasma cells 0.65, PC 45 × 10 ~ 9 / L. ESR 165mm / h, normal liver function, HBsAg negative, plasma protein T 129g / L, A 15g / L, G 114g / L. Protein electrophoresis: A.