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患者孙×,男,53岁,石灰厂工人,住院号74893.因上腹部胀痛、纳差、乏力、进行性消瘦二月余,于1980年3月7日来本院就诊,次日入院.体检:神清,恶液质貌,皮肤巩膜无黄染,浅表淋巴结不肿大.胸廓对称,心率82次/分,律齐,未闻杂音.两肺呼吸音略低,未闻罗音.腹平软,无腹水征.肝上界锁骨中线第五肋间,肝下界在右肋缘下锁骨中线处1厘米,剑突下4.5厘米,质硬、压痛、表面平滑.脾未触及.化验:肝功能正常.红细胞414万,血红蛋白12.3克%,白细胞8400,中性66%,淋巴33%,单核1%,血小板7万.尿常规:蛋白(+),白细胞少许,红细胞(-),上皮细胞(+),粘液丝(+).大便隐血试验(+),可见脂肪球.AFP(+).AKP21金氏单位.血浆蛋白电泳:白蛋白55.9%,球蛋白α_16.7%,α_26.7%,β8.9%,γ17.8%.血钠140毫当量/升,血钾4.83毫当量/升,血氯化物112.2毫当量/升,血钙5.4毫当量/升.
Patient Sun ×, male, aged 53, lime factory worker, hospital number 74893. Because of abdominal pain, anorexia, weakness, progressive weight loss February February, came to our hospital on March 7, 1980 and was admitted the next day Physical examination: Shen Qing, evil liquid appearance, skin sclera no yellow dye, superficial lymph nodes is not large. Symmetrical thoracic heart rate 82 beats / min, law Qi, unheard noise. Tone. Abdomen is soft, without ascites sign .High upper clavicle midline fifth intercostal space, the lower edge of the liver in the right subcostal clavicle midline at 1 cm, 4.5 cm under the xiphoid, hard, tender, smooth surface. Assay: Normal liver function: 3.14 million red blood cells, 12.3 grams of hemoglobin, 8400 leukocytes, 66% neutral, 33% lymphatic, 1% mononuclear, 70,000 blood platelets Urine: protein, leucocytes, erythrocytes -), epithelial cells (+), mucus silk (+) stool occult blood test (+), visible fat globule AFP (+) AKP21 gold unit Electrophoresis of plasma proteins: albumin 55.9%, globulin α_16.7 %, α_26.7%, β8.9%, γ17.8% .Sodium serum 140 meq / l, potassium 4.83 meq / l, blood chloride 112.2 meq / l, calcium 5.4 meq / l.