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病史摘要患者男,42岁。因发热、咳嗽、胸痛月余入院,既往10多年有反复发作性全身关节痛病史。体检:体温、呼吸、脉搏、血压正常。眉毛稀疏,双颊与鼻梁有紫红色蝶形红斑。左下肺叩诊稍浊,呼吸音减弱,右肺可闻及罗音。肝肋下1.5cm,剑下2.5cm,质软,轻压痛。两手指有Reynaud现象,两足趾末端水肿。化验:白细胞4500,中性68％,淋巴32％。红细胞315万,血红蛋白8.5g/dl,血沉80mm/h。尿蛋白(+++),红细胞0～2,白细胞3～5,颗粒管型0～1。血浆总蛋白5.8g/d1,A/G=2.3/3.5,r27.5/d1。锌浊度16单位。血清抗DNA抗体结合率42.9％。血查狼疮细胞阳性。IgG4575mg/d1,C_3
Summary of patient history Male, 42 years old. Due to fever, cough, chest pain and more than admissions, past 10 years of recurrent systemic joint pain history. Physical examination: body temperature, breathing, pulse, normal blood pressure. Sparse eyebrows, cheeks and nose with purple butterfly erythema. Lower left lung percussion slightly turbid, breath sounds weakened, the right lung can smell and rales. Liver ribs 1.5cm, sword under 2.5cm, soft, light tenderness. Two fingers have Reynaud phenomenon, two toe end edema. Laboratory: white blood cells 4500, 68% neutral, lymphatic 32%. 3.15 million erythrocytes, hemoglobin 8.5g / dl, ESR 80mm / h. Urinary protein (+++), red blood cells 0 to 2, leukocytes 3 to 5, granular tube 0 to 1. Plasma total protein 5.8g / d1, A / G = 2.3 / 3.5, r27.5 / d1. Zinc turbidity 16 units. Serum anti-DNA antibody binding rate of 42.9%. Blood check lupus cells positive. IgG4575mg / d1, C_3