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病历摘要患者,男,65岁。因下肢水肿一年零8个月,于1988年10月19日入院.自1987年2月起,发现双下肢可凹性水肿,时有时无,未重视.近半月来双下肢水肿明显加重,并波及到阴囊和阴茎。既往心脏有频发早搏和口腔顽固性溃疡。家族史无特殊.检查:体温36℃,脉搏80次/分,血压10.1/7.1kPa。营养差,面色(白光)白呈贫血貌。巩膜、皮肤无黄染,浅表淋巴结不肿大。两肺叩、听诊正常,心律规整,心率80次/分,心音低钝无杂音。腹软无压痛,腹水征(+),肝大3cm(后平脐),脾大2c
Patient summary, male, 65 years old. Due to lower extremity edema one year and eight months, was admitted to hospital on October 19, 1988. Since February 1987, found that both lower extremity concave edema, sometimes without, did not pay attention to nearly half of the edema of the lower extremities was significantly worse, And spread to the scrotum and penis. Prior heart has frequent premature beats and oral intractable ulcers. No special family history Check: temperature 36 ℃, pulse 80 beats / min, blood pressure 10.1 / 7.1kPa. Poor nutrition, looking (white) white anemia appearance. Sclera, no yellow skin, superficial lymph nodes is not enlarged. Pulmonary knock, auscultation normal, regular heartbeat, heart rate 80 beats / min, heart sound low blunt no noise. Abdominal tenderness without tenderness, signs of ascites (+), liver 3cm (after flat umbilical), splenomegaly 2c