论文部分内容阅读
病历摘要住院号A11010,陈××,男,37岁,已婚,工人,汉族,1977年3月11日入院主诉:食欲不振、腹胀消瘦二个月。现病史:二个月前无明显诱因的自觉乏力,四肢酸软,食欲不振,食后腹胀,恶心但无呕吐,无腹泻,腹痛,病中伴有不规则发烧(体温不详)四肢关节酸痛,面部呈褐色色素沉着,皮肤干燥脱屑,因病后食纳不佳,午后发烧,消瘦,肝大,在当地医院疑诊为肝硬化,未经系统治疗,而病情加重来我院求诊,门诊因其发烧,肝功有变化,皮肤色素沉着等以“结缔组织病”介绍入院。既往史:75年患肺结核,经抗痨药物治疗临床治愈。
Medical records Summary Hospital No. A11010, Chen × ×, male, 37 years old, married, worker, Han nationality, March 11, 1977 Admitted to hospital: Appetite, bloating and weight loss for two months. History of illness: Two months ago, there was no obvious incentive to conscious fatigue, limbs were soft, loss of appetite, bloating after eating, nausea but no vomiting, no diarrhea, abdominal pain, the disease accompanied by irregular fever (body temperature unknown) limb joint pain, Brown pigmentation, dry skin, scaling, due to poor health after eating, afternoon fever, weight loss, hepatomegaly, in the local hospital suspected of cirrhosis, without systemic treatment, and the disease to our hospital treatment, outpatient service Because of its fever, changes in liver function, skin pigmentation and other “connective tissue disease” introduced to hospital. Past history: 75 years of suffering from tuberculosis, clinically cured by anti-tuberculosis drugs.