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病历摘要女性,58岁。因反复发热伴频繁呕吐2周,于1985年2月12日入院。当时T37.8℃,P78次/分,R18次/分,血压110/80mmHg,神志清,精神萎,贫血貌,无浮肿。目不黄,皮肤粘膜未见瘀点。全身浅表淋巴结无肿大。心肺正常。腹软,肝肋下刚触及,质软,无触痛,脾未扪及。全身骨骼无疼痛与压痛。实验室检查,Hb6.1g％,WBC11,400/mm~3,P62％ L20％,M5％,E3％,异常浆细胞10％,血片中红细胞呈缗钱状凝集。血沉28mm/
Summary of medical records Female, 58 years old. Due to repeated fever with frequent vomiting for 2 weeks, on February 12, 1985 admission. At that time T37.8 ℃, P78 beats / min, R18 beats / min, blood pressure 110 / 80mmHg, conscious mind, spiritual wilting, anemia appearance, no edema. Head is not yellow, skin and mucous membrane no petechia. Systemic superficial lymph nodes without swelling. Cardiopulmonary normal. Abdomen soft, just touched under the ribs, soft, no tenderness, the spleen is not palpable. Whole body bones without pain and tenderness. Laboratory tests, Hb6.1g%, WBC11, 400 / mm ~ 3, P62% L20%, M5%, E3%, abnormal plasma cells 10%. ESR 28mm /