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病历介绍患者:金××,女,16岁,学生.初次病志号:29035;二次病志号:32569.病理号:26429. 患者因剧烈头痛、鼻塞、鼻涕带血、双耳聋闷感、发烧,于1975年4月28日入院(五官科)治疗.入院查体:T37.5℃,BP140/90mmHg.慢性病容,消瘦,心肺听诊无异常,腹软,肝脾未扪及.神经系统检查阴性.化验检查:Hb 10g,WBC_(13),100,N81%,L19%,血小板24.1万,出血时间:1分30秒,凝血时间3分10秒.鼻窦克瓦氏位X光片未见异常改变.耳鼻喉检查:双鼻腔有血性涕,鼻腔均为肿大之下鼻甲所阻塞,擦拭后有坏死组织脱落,双下甲溃烂.咽部充血,扁桃体不大.首次送病理活检回报为炎性脱落
Patient: Kim × ×, female, 16 years old, student. Initial disease number: 29035; Second disease number: 32569. Pathology: 26429. Patients with severe headache, stuffy nose, bloody nose, both ears deafness feeling , Fever, admitted to hospital (ENT) on April 28, 1975. Admission examination: T37.5 ℃, BP140 / 90mmHg. Chronic disease, weight loss, cardiopulmonary auscultation no abnormalities, abdominal soft, liver and spleen not palpable. The system examination was negative. Laboratory tests: Hb 10g, WBC_ (13), 100, N81%, L19%, platelet 241,000, bleeding time: 1 minute 30 seconds, clotting time 3 minutes 10 seconds. No abnormal changes. Otolaryngology examination: double nasal bloody tears, the nasal cavity are swollen under the turbinates blocked, necrotic tissue after wiping off, double under the ulceration. Pharyngeal hyperemia, tonsil is not the first time sent biopsy Reported as inflammatory exfoliation