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先证者,李某,男,35岁,农民。以“腹胀纳差10天”之主诉入院。10天前始因劳累过度,逐渐出现腹胀,呈持续性胀憋感,进饮食后加重,食欲减退,伴头昏,浑身酸软无力。既往无特殊病史,家庭中三代人,6位男性死于肝硬化、腹水。查体:T37℃,R20次/min,P80次/min,BP14/10 kPa。神志清,面色灰暗,皮肤干燥,心肺(-),蛙状腹,肝浊音界缩小,腹水征阳性,脾不大,肠鸣音3～4次/min,肝功能总胆红素16.1mmol/L,结合胆红素7.1mmol/L,GPT20 u,总蛋白76 g/L,球蛋白23 g/L,白蛋白53 g/L,白/球倒值1:2.31,甲肝(-),乙肝系列抗HBsAg6项(-),丙肝DNA、RNA(-)。B超示,肝硬化腹水,门静脉1.6 cm,肝脏CT扫描:肝硬化。
Proof, Lee, male, 35 years old, farmer. Admission to the main complaint of “abdominal distention anorexia 10 days.” 10 days ago because of overwork, progressive abdominal distension, was persistent inflation feeling, into the diet increased, loss of appetite, with dizziness, whole body weakness. No previous history of special medical conditions, three generations in the family, six men died of cirrhosis and ascites. Physical examination: T37 ℃, R20 times / min, P80 times / min, BP14 / 10 kPa. Consciousness, dark complexion, dry skin, cardiopulmonary (-), frog belly, liver dullness narrowing, positive signs of ascites, spleen not, bowel sounds 3 to 4 times / min, liver function total bilirubin 16.1mmol / L combined with 7.1 mmol / L of bilirubin, 20 ug of GPT, 76 g / L total protein, 23 g / L globulin, 53 g / L albumin and 1: Series anti-HBsAg6 (-), hepatitis C DNA, RNA (-). B ultrasound, liver cirrhosis, portal vein 1.6 cm, liver CT scan: cirrhosis.