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患者男性,39岁。因乏力、纳差2年,腹胀4个月于1992年12月8日入院。患者2年前出现乏力、纳差,继有齿龈出血、鼻衄,拟诊慢性活动性肝炎(乙肝)、肝炎后肝硬化,一直在门诊治疗,但疗效不佳。近4个月来出现腹胀、下肢水肿、尿量减至500ml/d左右入院。体检:体温37.4℃,脉搏80次/分,呼吸20次/分,血压18/8kPa。神志清,慢性肝病面容,皮肤、巩膜无黄染,全身散在针尖大小出血点,肝掌(+),颈部可见蜘蛛痣2枚,双下肢色素沉着,浅表淋巴结无肿大。心肺未见异常。腹部饱满,无腹壁静脉曲张,腹软无压痛,肝上界左锁骨中线第5肋间,肝下界肋下刚及,剑突下2cm,质硬,脾左锁骨中线肋下6cm,可触及脾切迹。肝肾区无叩痛,腹水征(+),双下肢无水肿。辅助检查:血白细胞2.5×10~9/L,中性0.71,淋巴0.29,红细胞3.46×10~(12)/L,血红蛋白103g/L,血
Male patient, 39 years old. Due to fatigue, anorexia 2 years, abdominal distension 4 months in December 8, 1992 admission. 2 years ago, patients with fatigue, anorexia, followed by bleeding gums, epistaxis, diagnosed chronic active hepatitis (hepatitis B), cirrhosis of hepatitis, has been in out-patient treatment, but poor efficacy. Appearing in the past 4 months abdominal distension, lower extremity edema, urine output reduced to about 500ml / d admission. Physical examination: body temperature 37.4 ℃, pulse 80 beats / min, breathing 20 beats / min, blood pressure 18 / 8kPa. Consciousness, chronic liver disease face, skin, sclera no yellow dye, the body scattered in the size of the tip of the bleeding point, the liver palpitus (+), visible spider nevus neck 2, both lower extremities pigmentation, superficial lymph nodes without swelling. Heart and lung no abnormalities. Abdomen full, no abdominal varicose veins, abdominal tenderness and no tenderness, the upper left hepatic artery midline 5 intercostal space, the lower extremity inferior rib cage and the xiphoid 2cm, hard, splenic left subclavian midline rib 6cm, palpable spleen Notch No percussion pain in the liver and kidney area, ascites sign (+), no lower extremity edema. Auxiliary examination: white blood cells 2.5 × 10 ~ 9 / L, neutral 0.71, lymphatic 0.29, red blood cells 3.46 × 10 12 / L, hemoglobin 103g / L, blood