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患者女,36岁,住院号98,1977年4月23日入院。六个月前无诱因食欲不振,颜面逐渐萎黄。多次就医,均对症治疗。以贫血待查住院。查体:体温35.8℃,脉搏120次/分,血压140/90毫米汞柱。贫血貌,皮肤和巩膜无黄染,无出血征。扁桃体Ⅱ°肿大,颌下有一个肿大的淋巴结1.5×1.5厘米,质硬,推之可移。心肺无异常,肝肋下1.5厘米,质硬,脾未扪及,神经系检查正常。化验:血红蛋白2.3克％,红细胞100万,白细胞2800,杆核4％,分叶43％,淋巴46％,嗜酸4％,单核3％,血小板2～3万,全片晚幼红细胞3个。两次血网织红细胞均3％,红细胞压积10％。3次骨髓穿刺干抽或稀释未获成功。肝功、谷丙转氨酶正常。便钩虫卵3次阴性。胸透心肺未见异常。诊断:再生障碍性贫血。
Female patient, 36 years old, hospital number 98, admitted to hospital on April 23, 1977. Six months ago, no incentive to loss of appetite, face gradually chlorosis. Repeated medical treatment, are symptomatic treatment. Awaiting hospitalization for anemia. Physical examination: body temperature 35.8 ℃, pulse 120 beats / min, blood pressure 140/90 mm Hg. Anemia appearance, skin and sclera no yellow dye, no bleeding sign. Tonsils Ⅱ ° enlargement, submandibular lymph nodes have an enlarged 1.5 × 1.5 cm, hard, push the removable. No abnormal heart and lung, liver ribs 1.5 cm, hard, spleen not palpable, check the normal nervous system. Laboratory tests: 2.3 grams of hemoglobin, 1 million red blood cells, white blood cells 2800, 4% of stem, leaf 43%, lymph 46%, 4% eosinophilic, mononuclear 3%, platelets 2 to 30,000, A Two blood reticulocytes were 3%, hematocrit 10%. Three bone marrow puncture or dilution did not succeed. Liver function, alanine aminotransferase normal. Hook egg 3 times negative. Thoracic heart and lung no abnormalities. Diagnosis: Aplastic anemia.