Past history: Two days ago, the patient had scattered petechiae and ecchymosis all over the body, especially on the limbs, accompanied by gingival bleeding, no bloody stool, hematuria, hematemesis, no fear of cold, fever and no cough. No medical treatment or treatment. There are still fresh petechiae today, and it is planned to be hospitalized for further examination and treatment. I had diarrhea four days ago. Since the onset, I have been fearless of cold and fever, and have no headache, dizziness, cough, expectoration, chest tightness, chest pain and shortness of breath. No abdominal distension or pain. Large urine volume, normal urine, no hematuria and bloody stool. Appetite and sleep are normal. There is no edema in both lower limbs.
Past history: I had a similar medical history before 10, and got better after treatment. The specific diagnosis and treatment are unknown. Deny the history of hypertension, diabetes, hepatitis, tuberculosis, hemophilia, etc. Denied a history of trauma, surgery and blood transfusion. Deny the history of drug and food allergy. Vaccination history is unknown.
Personal resume: Born and raised, I have worked in ZZ for nearly five years and engaged in cosmetics manufacturing for many years. Does not involve epidemic water and infected areas. No history of alcoholism. Smoking history is 6 years, 10 cigarette/day.
Marriage and childbearing history: unmarried and childless.
Family history: deny that there are patients with similar diseases in the family, and deny that there are diseases such as hepatitis, tuberculosis, hypertension, diabetes, hemophilia and tumor in the family.
To physically block an opposing player, as in ice hockey or lacrosse.
T 36.5℃ P 80 times/min R 20 times/min BP 1 10/70mmHg.
Normal development, malnutrition, conscious, slightly tired, walking to the hospital, supine position, automatic posture, body coordination. Direction force and calculation force are normal. Mild anemia, no cyanosis on face, mouth and lips. No jaundice. The whole body skin is scattered with petechiae and ecchymosis, not brown. The left supraclavicular fossa can reach several mung bean-sized lymph nodes, with medium quality, no tenderness, good mobility and no ulceration of superficial skin. Skull and facial features are normal, pupils on both sides are concentric, with a diameter of about 3mm, sensitive to light reflection, and there is no abnormal secretion in external auditory canal and nasal cavity. The middle of the tongue is spread out, and no swelling is found in bilateral tonsils. The jugular vein is not dilated, the neck is soft, there is no resistance, the trachea is centered, and the thyroid gland is not enlarged. There is no deformity in the chest, no tenderness in the sternum, clear breathing sounds in both lungs, and no dry and wet rales in both lungs. The heart boundary is normal, the heart rate is 80 beats/min, the rhythm is regular, and no pathological murmur is found in the auscultation area of each valve. The abdomen is flat and soft, without gastrointestinal type, peristalsis spreads to abdominal varicose veins, without mass, tenderness and rebound pain. The liver is 2CM below the right rib, with medium quality, without tenderness, and without tenderness under the spleen rib. Slight percussion pain in the liver area, no percussion pain in both kidneys, negative motor dullness, and bowel sounds about 4-5 times per minute. The external genitalia and perianal area were not examined. There is no deformity in the spine and limbs, normal mobility, no tenderness and percussion pain in the spine, no edema in both lower limbs, normal muscle strength and tension in the limbs, physiological reflex and no pathological symptoms.
accessory examination
Blood RT: white blood cells:12./kloc-0 /×10 * 9/L, HGB: 1 18g/L, red blood cells: 5.25×10 */kloc.
Preliminary diagnosis:
Causes of thrombocytopenia