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一、病历摘要男,67岁,住院号34644,于1983年3月22日因气促3月余,颜面浮肿5天住院。病者于82年12月咳嗽,咯白色粘液痰,83年2月中旬咳嗽增剧伴气促,拟诊“肺结核”,虽接受抗结核治疗、但症状反日见明显。近5天因颜面浮肿,于某医院照全胸片疑为“肺癌”。 1959年曾患“肺结核”经治疗已钙化。体查:体温36.5℃,脉搏124次,呼吸32次,血压170/110,神志清,营养欠佳,气促,呈端坐呼吸、颜面浮肿如满月脸呈紫褐色,两眼裂消失。颈软、粗短,颈围46cm,气管居中,甲状腺未见肿大,两侧颈静脉极度怒张,右锁骨上窝可扪及淋巴结如核桃大、无压痛、不可移动,胸壁静脉怒张明显呈网状。心肺无异常。腹软平坦、叩诊呈鼓者,腹壁静脉怒张明显,全腹均无压痛。肝触诊于右肋下两横指,质中等、边缘整、表面光滑。四肢呈中等浮肿,并见指压留痕、鼓槌指(趾)。实验室检查:血沉33mm/小时。红细胞348万。血红蛋白9.8g。白细胞9600,杆状2％,多核79％,淋巴15％,单核2％,酸性2％。
First, the medical record summary Male, 67 years old, hospital number 34644, on March 22, 1983 due to shortness of breath more than 3 months, facial edema 5 days hospitalization. The patient developed cough in December of the year 82, with slightly muciculous sputum. In the mid-February 83, cough and hyperpigmentation was accompanied by shortness of breath. The patient was diagnosed as having “tuberculosis”. Although he received anti-tuberculosis treatment, his symptoms were obvious from day to day. In the past 5 days, because of facial edema, he was suspected of having “lung cancer” in a hospital. In 1959, he suffered from “tuberculosis” and was treated with calcification. Physical examination: body temperature 36.5 °C, pulse 124, breathing 32 times, blood pressure 170/110, clear-minded, poor nutrition, shortness of breath, was sitting breathing, facial edema, such as full moon face was purple brown, two eyes disappeared. Neck soft, short, neck circumference 46cm, central trachea, no enlargement of thyroid gland, extreme jugular vein distension on both sides, right supraclavicular fossa may be paralyzed and lymph nodes such as large walnuts, no tenderness, immobility, chest wall venous distension Meshed. No abnormalities in heart and lungs. The abdomen was soft and flat, and the percussion was a drum. Abdominal vein engorgement was evident, and there was no tenderness in the entire abdomen. The liver was palpated on the two lower right ribs, with medium quality, smooth edges, and a smooth surface. The middle limbs are swollen and see the finger marks, drumsticks (toes). Laboratory examination: ESR 33mm/hour. 3.48 million red blood cells. Hemoglobin 9.8g. White blood cells 9600, rod 2%, polynuclear 79%, lymph 15%, mononuclear 2%, acidic 2%.