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沈某,男,47岁,住院号164939,1979年3月29日入院。患者自1976年7月起,感腰部持续性隐痛,遇寒冷加重,两上肢不能抬举,颈项肩胛酸痛。同年发现尿色深褐,放置3～4天后,即变为黑色,曾服消炎痛等治疗,未见明显好转。曾患疟疾、肺结核及溃疡病。家属中无近亲结婚或其他遗传性疾病。体检:神清,自动体位,体温37.3℃,血压正常,除左耳垂发现黄褐色色素斑约1×0.5厘米外,全身皮肤无明显色素沉着,巩膜无色素斑。心肺正常,肝脾来及,肾区无叩痛,腰椎轻度右侧突,并有叩痛,弯腰受限。
Shen a, male, 47 years old, hospital number 164939, March 29, 1979 admission. Patients from July 1976 onwards, the sense of persistent lumbar pain, in case of aggravating cold, upper extremity can not lift, neck shoulder ache. The same year found dark brown urine, placed 3 to 4 days, that is turned black, had taken indomethacin and other treatment, no significant improvement. Had malaria, tuberculosis and ulcer disease. No relatives in the family were married or other hereditary diseases. Physical examination: God clear, automatic position, body temperature 37.3 ℃, normal blood pressure, in addition to the left earlobe found brown pigment pigmentation of about 1 × 0.5 cm, the whole body no obvious pigmentation, sclera no pigmentation. Normal cardiopulmonary, liver and spleen and kidney area without percussion pain, mild right lumbar protrusion, and percussion pain, bending limited.