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病历摘要 赵某,男,57岁。因脾大4年于1987年3月4日入院。1983年4月健康体检时发现脾大,触诊脾在左肋下约2cm,质中偏硬,其他无阳性发现,未重视。1986年4月再次体检,脾大9cm,触痛(-),肝功能正常,因无任何症状,建议动态观察。1987年2月复查,脾大平脐,血红蛋白91g/L,血小板79×10~9/L。为明确诊断,收住院。患者精神、饮食好,大小便正常,近半年来刷牙时偶有出血现象。既往无肝炎、黑热病、血吸虫病史,幼年曾患“疟疾”和“伤寒”。无疫水、疫畜接触史。
Medical summary Zhao, male, 57 years old. Four years due to splenomegaly was admitted to hospital on March 4, 1987. April 1983 when the physical examination found splenomegaly, palpation of the spleen in the left rib about 2cm, the quality of partial hard, no other positive findings, no attention. 1986 April again physical examination, splenomegaly 9cm, tenderness (-), normal liver function, due to no symptoms, it is recommended dynamic observation. February 1987 review, splenomegaly, hemoglobin 91g / L, platelet 79 × 10 ~ 9 / L. To confirm the diagnosis, admitted to hospital. The spirit of the patient, good diet, normal urine, occasional bleeding when brushing teeth nearly six months. Past history of hepatitis, kala-azar, schistosomiasis, juvenile “malaria” and “typhoid fever”. No water, livestock contact history.