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病例摘要例一,华××,男孩,7岁。住院号92247,于1961年5月6日入院。主诉:全身发黄,腹部肿块约一年。患儿于一年前家中发现身上与眼球发黄、时轻时重,并伴有间歇性发烧、同时发现腹部有肿块,逐渐增大。发病后食欲减退,消瘦。无出血与吐血情况。在外治疗无效,疑为黑热病介绍来我院治疗。既往未患过肝炎,未接种卡介苗,父母否认结核与性病史,家族中是否有类似疾病不详。体格检查:体温37.2℃,脉搏108次/分,呼吸28次/分。血压120/70毫米汞柱。营养情况较差,面色苍黄,慢性病容。皮肤轻度黄染,全身浅在淋巴结
Case Summary Example 1, Hua × ×, boy, 7 years old. Hospital number 92247, was admitted on May 6, 1961. Chief complaint: whole body yellow, abdominal mass about a year. Children found in the body a year ago with yellow eyes and body, when light weight, and accompanied by intermittent fever, while found abdominal mass, gradually increased. After the onset of loss of appetite, weight loss. No bleeding and vomiting blood situation. Out of treatment is invalid, suspected to be introduced to our hospital treatment of kala-azar. No prior history of hepatitis, BCG vaccination, parents denied history of tuberculosis and sexually transmitted diseases, whether the family has similar diseases unknown. Physical examination: body temperature 37.2 ℃, pulse 108 beats / min, breathing 28 beats / min. Blood pressure 120/70 mm Hg. Poor nutrition, pale yellow, chronic disease. Skin mild yellow dye, the body shallow in the lymph nodes