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病历摘要患者男性,30岁,住院号130635,于1959年7月13日因脸色蒼白,心慌,无力四个月,齿齦出血二个月而入院。在某医院診断为貧血而接受鉄剂和維生素B_(12),治疗无效,且觉症状加重,并发生鼻衄,遂至本院求治。既往史无特殊,亦无特殊药物接触史。查体:发育营养中等,重病容,全身皮肤蒼白,并有散在出血点,浅表淋巴結不肿大,巩膜无黃染,牙齦有血(?)。肺清朗,心界不大,心尖部有吹风性收縮期杂音,腹軟,肝脾未捫及,下肢无浮肿,外生殖器无异常。化驗:血紅蛋白2.8克％,紅細胞97万/立方毫米,网織紅細胞0.2％,白細胞1900/立方毫米,中性杆状核9％,中性分叶核13％,淋巴細胞76％,单核細胞1％,嗜酸粒细胞1％,血小板15,000/立方毫米,尿粪常規无异常,血浆白蛋
Summary of medical records Male patient, 30 years old, hospital 130635, on July 13, 1959 because of pale, palpitation, weakness for four months, bleeding gums for two months and admitted to hospital. In a hospital diagnosed with anemia and accept agents and vitamin B_ (12), the treatment is invalid, and the symptoms were aggravated, and the occurrence of epistaxis, then to our hospital for treatment. No previous history, no history of exposure to special drugs. Physical examination: development of moderate nutrition, severe disease, the body pale, and scattered bleeding point, superficial lymph nodes are not swollen, scleral no yellow dye, gingival blood (?). Qinglian lung, heart is not, apical hair blowing systolic murmurs, abdominal soft, liver and spleen not palpable, lower extremity no edema, no abnormal genitals. Assay: hemoglobin 2.8 g%, erythrocyte 970,000 / mm 3, reticulocyte 0.2%, leukocyte 1900 / mm 3, neutral rod core 9%, neutral leaf core 13%, lymphocyte 76%, monocyte 1%, 1% eosinophils, platelets 15,000 / cubic millimeter, no abnormal urinary manure routine, plasma white eggs