论文部分内容阅读
患者男性,34岁,未婚。12岁时体检发现肝睥肿大,其原因不明,当时也无任何不适。22岁起经常感冒发热,严重时出现休克,23岁时曾因“胆道感染”住院,作剖腹探查,未发现明显异常,术后肝脾仍慢性肿大。至今,无黄疸、呕血、黑便、出血质倾向史。无其他疾病史,无烟酒嗜好史。其妹患有同病,已行脾切除,术后诊断为脾功能亢进。体检:一般情况好,神志清,颈软,巩膜无黄染,血压110/80,心率80次,律齐,无病理性杂音,两肺呼吸音清晰。腹柔软,肝肋下2cm,剑突下7cm,质中等,无结节,无压痛;脾肋下平脐,上及第9肋间,质中,活动尚可,表面无结节;无腹水征,无肿块可摸及。肾区无叩痛,无肿块。四肢无异常。
Male patient, 34 years old, unmarried. At age 12, a liver enlargement was detected on a physical examination, for unknown reasons and without any discomfort. 22-year-old often cold and fever, severe shock, 23-year-old had “biliary tract infection” hospital for exploratory laparotomy, no significant abnormalities, liver and spleen are still chronic swelling. So far, no jaundice, hematemesis, melena, bleeding tendency. No history of other diseases, no history of alcohol-free drinks. His sister suffering from the same disease, splenectomy has been performed, postoperative diagnosis of hypersplenism. Physical examination: the general situation is good, clear consciousness, neck soft, sclera no yellow dye, blood pressure 110/80, heart rate 80 times, law Qi, no pathological murmur, clear breath sounds of both lungs. Abdomen soft, liver ribs 2cm, xiphoid 7cm, medium quality, no nodules, no tenderness; Spleen ribs flat umbilical, and the 9th intercostal, quality, activity is acceptable, the surface nodules; no signs of ascites , No lumps can touch and. No pain in the kidney area, no lumps. No abnormalities in limbs.