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患者,江××,男性,35岁,住院号292397。于1990年6月21日因右上腹隐痛伴黄疸20余天入院,有“乙肝”病史10年,1989年曾因“肝硬化”腹水住某院治疗。入院休检:面色晦暗、肝掌、无蜘蛛痣,巩膜皮肤轻度黄染。心肺无异常。腹软,中上腹稍隆起,腹壁静脉可见,肝在剑下3cm,脾肋下5cm,腹水征阳性。入院后化验血红蛋白134g/L,红细胞3.82×10~(12)/L。白细胞4.1×10~9/L.淋巴0.28,中性0.72,血小板74×
Patient, Jiang XX, male, 35 years old, hospital number 292397. On June 21, 1990 due to pain in the right upper quadrant with jaundice more than 20 days admission, “Hepatitis B” history of 10 years, in 1989 had “cirrhosis” ascites live in a hospital treatment. Hospitals closed: looking dull, liver palms, no spider nevus, scleral mild yellow stained skin. No abnormal heart and lung. Abdominal soft, slightly elevated in the abdomen, abdominal veins visible, the liver in the sword 3cm, 5cm under the spleen ribs, ascites sign positive. After admission, hemoglobin 134g / L, red blood cells 3.82 × 10 ~ (12) / L. White blood cells 4.1 × 10 ~ 9 / L. Lymphatic 0.28, neutral 0.72, 74 × platelets