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患者,男性,57岁,因牙痛、咳血丝痰2个月,伴高热1周于1990年3月22日入院。20年前有“支气管炎”,去年有“十二指肠球部溃疡出血”病史。体检:T40℃,慢性病容,消瘦,皮肤无出血点、腋窝、腹股沟等处浅表淋巴结似黄豆至蚕豆大小,散在分布,无粘连,无压痛;双扁桃体Ⅰ°,无分泌物,心率120次/分,律整,双下肺可闻及较多湿罗音,胸骨压痛;肝肋下3cm,脾肋下2cm,肝脾质软,无触痛,WBC15.5×10~9/L,其中原淋0.06,幼淋0.04,RBC2.04×10~12/L,Hb 54g/L,Pl75×10~9/L,骨髓涂片:增生活跃,原淋0.51,幼淋0.20,以小细胞为主,POX(-),CLE(-),NSE(-),HI 98(-),
The patient, male, 57 years old, was admitted to hospital on March 22, 1990 due to a toothache, coughing sputum for 2 months and fever with 1 week. 20 years ago, “bronchitis” last year, “duodenal ulcer bleeding” history. Physical examination: T40 ℃, chronic disease, weight loss, skin no bleeding point, axillary, groin and other places superficial lymph nodes like soybeans to broad bean size, scattered distribution, no adhesions, no tenderness; double tonsil I °, no secretions, heart rate 120 / Min, law, double lower lung can be heard and more wet rales, sternal tenderness; liver ribs 3cm, Spleen ribs 2cm, liver and spleen soft, no tenderness, WBC15.5 × 10 ~ 9 / L, The original leaching 0.06, young leaching 0.04, RBC2.04 × 10-12 / L, Hb 54g / L, Pl75 × 10 ~ 9 / L, bone marrow smear: hyperplasia, Lord, POX (-), CLE (-), NSE (-), HI 98 (-),