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患者,女,18岁,以面色苍白,肝脾大9年入院。自9年前突感左上腹不适、触及左上腹部肿物,伴黄尿、牙龈出血、鼻衄。B超检查示:肝、脾大。而后行对症治疗无明显疗效至今。皮肤、巩膜黄染及尿呈黄红色逐渐加重。未有月经史,家族史否认有类似病变。体检:T36.4℃,P72次/分,R18次/分,BP11.6/4.6KPa,体重36kg。发育不良,中度贫血貌,全身皮肤、粘膜轻度黄染,头颅呈方颅征,具前额、顶部隆起、颧骨高耸,眼距宽,鼻梁塌陷等典型表现。右颈下及右腋窝淋巴结可触及肿大,胸廓呈鸡胸,双肺未闻及干湿性罗音,心界稍大,心率70次/分,心律齐,各瓣膜听诊区未闻及器质性杂音,腹软无压痛。肝肋下2cm—3cm,剑突下3cm,质软无压痛,脾呈中等大,质偏硬,无触痛,边界清。腹水征阴性。临床诊断:肝、脾大、黄疸待查,早期肝硬化,慢性活动性肝炎。
Patient, female, 18 years old, to pale, large splenomegaly admitted for 9 years. Suddenly left upper quadrant discomfort 9 years ago, touched the upper left abdominal mass, with yellow urine, bleeding gums, epistaxis. B-ultrasound showed: liver, splenomegaly. Symptomatic treatment followed by no significant effect so far. Skin, sclera yellow dye and urine yellowish red gradually increased. No history of menstruation, family history denied a similar disease. Physical examination: T36.4 ℃, P72 times / min, R18 times / min, BP11.6 / 4.6KPa, weight 36kg. Hypoplasia, moderate anemia appearance, body skin, mucous membrane mild yellow dye, head was square cranial syndrome, with forehead, the top of the bulge, cheekbones towering, wide eye, nose collapse and other typical performance. Right neck and right axillary lymph nodes can be touched enlargement, thoracic was chicken breast, lungs unheard of both wet and dry rales, heart slightly larger, heart rate 70 beats / min, heart rate Qi, the valve auscultation area did not smell and quality Sexual noise, soft abdominal tenderness. Under the liver ribs 2cm-3cm, 3cm under the xiphoid, soft without tenderness, spleen was medium large, qualitative partial hard, no tenderness, border clear. Ascites sign negative. Clinical diagnosis: liver, splenomegaly, jaundice pending investigation, early cirrhosis, chronic active hepatitis.