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张××,男,60岁,退休工人,住院号217028。因头痛、头晕、乏力半年,胸闷伴间歇性腹绞痛半月,加重3天,于1983年7月16日入院。腹绞痛发作时伴大汗、恶心、呕吐,四肢沉重麻木。往有30年用钖壶饮酒史,并常火上加温,每日饮酒半斤以上。查体:体温36.5℃,脉搏94次/分,呼吸18次/分,血压150/100mmHg。铅性面容,下齿龈见铅线。心率94次/分,律整,心音稍低钝,肺部(一),腹平软,无压痛及反跳痛,未扪及包块。无垂腕及垂足,四肢皮肤浅感觉稍减退,肌力肌张力正常,生理反射存在,病理反射未引出。实验室检查:血红蛋白10.5g％,白细胞5,000/mm~3,中性58％,淋巴42％。血小板17万/mm~3,血沉14mm/小时,网织红细胞0.5％,嗜碱性点彩红细胞30,000/100万红细胞。尿紫质(++++)
Zhang × ×, male, 60 years old, retired workers, hospital number 217028. Due to headache, dizziness, fatigue six months, chest tightness with intermittent abdominal cramps half, aggravating three days, in July 16, 1983 admission. Abdominal cramps with sweating, nausea, vomiting, limbs and heavy numbness. To 30 years of drinking pot history, and often fire on the heat, drinking more than half a catty a day. Physical examination: body temperature 36.5 ℃, pulse 94 beats / min, breathing 18 beats / min, blood pressure 150 / 100mmHg. Lead face, under the gum see the lead line. Heart rate 94 beats / min, the law, the heart sounds a little lower blunt, the lungs (a), abdominal soft, no tenderness and rebound tenderness, palpable mass. There is no vertical wrist and foot drop, limb skin feel slightly diminished, muscle tone muscle normal, there is physiological reflection, pathological reflex did not lead. Laboratory tests: hemoglobin 10.5g%, white blood cells 5,000 / mm ~ 3, neutral 58%, lymph 42%. Platelets 170,000 / mm ~ 3, erythrocyte sedimentation rate 14mm / hour, reticulocyte 0.5%, basophilic erythrocytes 30,000 / 1 million red blood cells. Urine (++++)