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病历摘要患者曹××,女性,23岁,未婚,农村社员,住院号213178。于1977年6月25日以十余日来月经多,全身无力、低热来我院就诊。病人自诉:既往除有皮肤病(白癜风)外,一向健康。来院前12日,出现月经过多,全身无力,面色发黄。一周后,有低热、头晕、头痛、腰痛、四肢皮肤有出血点。因本地治疗效果不佳而来我院。在门诊及住院的检查:体温稍高,脉略快,血压150/90mmHg,呈贫血貌,双腋下各有一杏核大淋巴结,四肢有散在皮下出血点,余无异常。化验:Hb5.5g％,WBC6,000,B1％,E3％,幼粒1％,St2％,S58％,L28％,异淋7％。数100个白细胞时见晚幼红细胞35个。网织红细胞17.6％,血小板2,6万。尿常规:蛋白(++),RBC30～100,WBC5～6。尿细菌培养,未长致病菌。
Patient summary of the medical record Cao × ×, female, 23 years old, unmarried, rural member, hospital number 213178. On June 25, 1977 to more than 10 days of menstruation, general weakness, fever to our hospital. Patient’s private prosecution: In addition to the past, except skin disease (vitiligo), has always been healthy. To the hospital on the 12th, there is too much menorrhagia, general weakness, looking yellow. A week later, there are fever, dizziness, headache, back pain, limbs, bleeding spots. Due to poor local treatment from our hospital. In the outpatient and inpatient examination: slightly higher body temperature, pulse slightly faster, blood pressure 150 / 90mmHg, anemia appearance, each with a double armpit apricot nuclear lymph nodes, scattered limbs in the subcutaneous bleeding point, I no exception. Laboratory: Hb5.5g%, WBC6,000, B1%, E3%, baby 1%, St2%, S58%, L28%, different leaching 7%. When the number of 100 white blood cells see late young erythrocytes 35. Reticulocyte 17.6%, platelets 26000. Urine: protein (++), RBC30 ~ 100, WBC5 ~ 6. Urine bacterial culture, not long pathogenic bacteria.