從貧血淺談疾病的病因診斷20121024

1、Department of HematologyDepartment of HematologyThe First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC1溫州醫(yī)學(xué)院附屬第一醫(yī)院血液科梁彬Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC病因診斷概述病因診斷概述貧血概述及病因診斷的基本思路貧血概述及病因診斷的基本思路病

2、例討論病例討論2Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCv疾病的治療分為對(duì)癥治療和病因治療，其中病因治療是根本，只有明確病因，才能制定科學(xué)、適當(dāng)治療的方案。v醫(yī)學(xué)基礎(chǔ)課程，如：生理學(xué)、生物化學(xué)、病理生理學(xué)為我們理解疾病病因打下很好的基礎(chǔ)。3Department of Hematology Department of Hematology The First Affiliated Hospita

3、l of WMCThe First Affiliated Hospital of WMC確診的三大支柱v病史v體格檢查v輔助檢查4Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC診斷過(guò)程的重要原則診斷過(guò)程的重要原則v病史和詳盡的臨床檢查是相當(dāng)重要的；v首先考慮常見(jiàn)病、多發(fā)病v危險(xiǎn)的疾病在診斷的開(kāi)始就不要忽視；v要盡量拓寬思路，避免過(guò)于狹隘。5Department of Hematology Depar

4、tment of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC診斷過(guò)程圖解6病史收集、整理一般情況的評(píng)價(jià)（擬診或確診）經(jīng)驗(yàn)直覺(jué)知識(shí)診斷治療觀察儀器設(shè)備附加檢查治療過(guò)程觀察治療觀察Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC病因診斷概述病因診斷概述貧血概述及病因診斷的基本思路貧血

5、概述及病因診斷的基本思路病例討論病例討論7Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC貧血是一種疾病的診斷嗎？v貧血“癥”是血液科門(mén)診最常見(jiàn)的主訴之一，也是許多系統(tǒng)性疾病的全身表現(xiàn)之一v不是！v貧血是一個(gè)需要解釋的實(shí)驗(yàn)室異常8Department of Hematology Department of Hematology The First Affiliated Hospital of WMCT

6、he First Affiliated Hospital of WMC9貧血的定義v人體外周血紅細(xì)胞容量的減少，低于正常范圍下人體外周血紅細(xì)胞容量的減少，低于正常范圍下限的一種常見(jiàn)的限的一種常見(jiàn)的臨床表現(xiàn)臨床表現(xiàn)。臨床常以血紅蛋白濃度代替紅細(xì)胞容量。臨床常以血紅蛋白濃度代替紅細(xì)胞容量。Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC Department of Hematolofy Departmen

7、t of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCDepartment of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC12Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCTh

8、e First Affiliated Hospital of WMC13v原發(fā)病的臨床表現(xiàn)；原發(fā)病的臨床表現(xiàn)；v貧血本身引起的癥狀；貧血本身引起的癥狀；v由于含鐵酶活力降低引起的癥狀。由于含鐵酶活力降低引起的癥狀。 粘膜粘膜 口、舌炎、舌乳頭萎縮、吞咽困難口、舌炎、舌乳頭萎縮、吞咽困難（Plummer-VinsonPlummer-Vinson綜合征）外胚葉外胚葉 皮膚、毛發(fā)、指甲皮膚、毛發(fā)、指甲神經(jīng)系統(tǒng)神經(jīng)系統(tǒng) 神經(jīng)痛（以頭痛為主）、末梢神經(jīng)炎、精神、行為方面的神經(jīng)痛（以頭痛為主）、末梢神經(jīng)炎、精神、行為方面的異常，例如注意力不集中，易激動(dòng)、精神遲滯和異食癖。異常，例如注意力不集中，易激動(dòng)、精

9、神遲滯和異食癖。Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC14舌炎舌炎反甲反甲Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC15Department of Hematolofy Department

10、of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC16正常紅細(xì)胞正常紅細(xì)胞缺鐵性貧血的紅細(xì)胞缺鐵性貧血的紅細(xì)胞Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC17Department of Hematolofy Department of Hematolofy The First

11、Affiliated Hospital of WMCThe First Affiliated Hospital of WMC18Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC19Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospi

12、tal of WMC20Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCDepartment of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCDepartment of Hematolofy Department of Hemat

13、olofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC23Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC24Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First

14、Affiliated Hospital of WMC25Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCDepartment of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCDepartment of Hematolofy Dep

15、artment of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC28Department of Hematolofy Department of Hematolofy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC291.1.紅細(xì)胞滲透性增高紅細(xì)胞滲透性增高- -遺傳性球形紅細(xì)胞增多癥遺傳性球形紅細(xì)胞增多癥Department of Hematology Department

16、 of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC診斷步驟v是否存在貧血以及程度v貧血的分類(lèi)形態(tài)學(xué)分類(lèi)骨髓反應(yīng)性分類(lèi)v病因診斷30診斷思維：必須密切結(jié)合病史、體檢和實(shí)驗(yàn)室檢查，并按不同人群的疾病譜從常見(jiàn)病到罕見(jiàn)病，切忌先入為主。 病因診斷是臨床醫(yī)師診斷的終極目標(biāo)！Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated

17、 Hospital of WMC貧血的臨床表現(xiàn)v血紅蛋白的生理功能：攜氧【1gHb1.34 ml O2】v臨床表現(xiàn)呈非特異性，以缺氧為基礎(chǔ)，皮膚粘膜色澤變化為特征v影響臨床表現(xiàn)的因素病因血容量速度機(jī)體代償和耐受程度31Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC32血常規(guī)v最基本的血液學(xué)檢查：RBC、HB、HCT。v紅細(xì)胞指數(shù)：MCH= MCV=MCHC=(%)100)/(HCTdLgHb）uLR

18、BCLgHb/10()/(6)/10(10(%)6uLRBCHCT一個(gè)提醒：血常規(guī)國(guó)際單位和常用單位的轉(zhuǎn)換Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC33貧血程度的判斷分級(jí)分級(jí) 血紅蛋白（血紅蛋白（g/Lg/L） 臨床表現(xiàn)臨床表現(xiàn) 輕度輕度 1201209191癥狀輕微癥狀輕微 中度中度 90906161體力勞動(dòng)后感到心悸、氣短體力勞動(dòng)后感到心悸、氣短 重度重度 60603131臥床休息時(shí)也感心悸

19、、氣短臥床休息時(shí)也感心悸、氣短 極度極度 3030常合并貧血性心臟病常合并貧血性心臟病 知識(shí)點(diǎn)：貧血臨床表現(xiàn)的輕重不僅與血紅蛋白濃度有關(guān)，更取決于血紅蛋白下降的速度、機(jī)體代償能力和耐受程度。Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC34Department of Hematology Department of Hematology The First Affiliated Hospital o

20、f WMCThe First Affiliated Hospital of WMCDepartment of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC36如何尋找病因線索？v病史：全面深入現(xiàn)病史：貧血發(fā)生時(shí)間、速度、程度、并發(fā)癥、誘因、干預(yù)治療的反應(yīng)；既往史：以往是否診斷過(guò)貧血、慢性疾病史、手術(shù)史、服藥史個(gè)人史：飲食史、排便習(xí)慣、飲酒史、危險(xiǎn)因素暴露史月經(jīng)生育史家族史：遺傳背景知識(shí)點(diǎn)：詢(xún)問(wèn)病史要特別注意原發(fā)病癥狀、排便情

21、況、服藥史、飲食營(yíng)養(yǎng)史、月經(jīng)生育史、毒物接觸史和家族史。小常識(shí)：每次月經(jīng)周期約失血3050毫升，失鐵量約1525毫克； 婦女在整個(gè)妊娠期所需鐵的總量約為925mg，哺乳婦女每天需求鐵24mg/dDepartment of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC37如何尋找病因線索？ v體格檢查：全面系統(tǒng)生命體征：TPR一般情況：營(yíng)養(yǎng)、面容心臟貧血貌皮膚出血點(diǎn)鞏膜黃染淺表淋巴結(jié)肝脾腫大毛發(fā)、反甲、舌像直腸指檢Depart

22、ment of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC38如何尋找病因線索？v實(shí)驗(yàn)室檢查：循序漸進(jìn)血常規(guī)（含網(wǎng)織紅細(xì)胞計(jì)數(shù)）血涂片血生化：肌酐、鈣、總膽、直膽、乳酸脫氫酶、總蛋白和白蛋白進(jìn)一步的檢查骨髓檢查鐵代謝指標(biāo)、葉酸和B12水平、血紅蛋白電泳、Coombs試驗(yàn)等一個(gè)提醒：選擇覆蓋每一個(gè)可能病因的“霰彈槍”式檢驗(yàn)不僅浪費(fèi)，而且提示該醫(yī)生缺乏思路？！Department of Hematology Departmen

23、t of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC外周血涂片v觀察制作良好的血涂片是關(guān)鍵，可能因此而確診。v觀察內(nèi)容：紅細(xì)胞形態(tài)、染色、細(xì)胞內(nèi)包涵體、白細(xì)胞和血小板、異常細(xì)胞。39球形紅細(xì)胞鐮刀狀紅細(xì)胞緡錢(qián)樣紅細(xì)胞Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC骨髓檢查v骨髓穿

24、刺：骨髓細(xì)胞增生程度、細(xì)胞成分、比例和形態(tài)變化。v骨髓活檢：造血組織的結(jié)構(gòu)、增生程度、細(xì)胞成分和形態(tài)變化。v必須注意：骨髓取樣的局限性。40Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC病因診斷概述病因診斷概述貧血概述及病因診斷的基本思路貧血概述及病因診斷的基本思路病例討論病例討論41Department of Hematology Department of Hematology The Firs

25、t Affiliated Hospital of WMCThe First Affiliated Hospital of WMC病例1v病歷摘要病歷摘要v男性，47歲，乏力、面色蒼白伴心悸1個(gè)月。v患者1個(gè)月前無(wú)明顯原因逐漸感乏力、心悸，上樓是癥狀加重，同事發(fā)現(xiàn)其“面色不好”，無(wú)發(fā)熱。1周前到當(dāng)?shù)蒯t(yī)院檢查，診為“貧血”（具體不詳），未予治療。病后進(jìn)食正常，不挑食，小便及睡眠均正常，體重?zé)o明顯下降。近1年來(lái)發(fā)現(xiàn)大便后滴血或便紙上帶血，未引起重視。無(wú)胃腸疾病、高血壓、肝病和心臟病史。職業(yè)為出租車(chē)司機(jī)。無(wú)煙酒嗜好。子女身體健康，無(wú)遺傳病家族史。Department of Hematology Dep

26、artment of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCv查體：T36，P102次/分，R18次/分，BP137/70mmHg。貧血貌，皮膚未見(jiàn)皮疹和出血點(diǎn)，淺表淋巴結(jié)未觸及腫大。鞏膜無(wú)黃染，瞼結(jié)膜和口唇蒼白，舌面正常，甲狀腺不大。雙肺未聞及干濕性啰音。心界不大，心率102次/分，律齊，心尖部可聞及2/6級(jí)收縮期吹風(fēng)樣雜音。腹平軟，無(wú)壓痛，肝脾肋下未觸及，移動(dòng)性濁音（-）。雙下肢無(wú)水腫。v實(shí)驗(yàn)室檢查：血常規(guī)：Hb 76g/L，RBC 3.01012/L，MCV 7

27、2fl，MCH 21pg，MCHC 24%,WBC 7.5109/L，分類(lèi)正常，PLT 305109/L，Ret 0.015。糞常規(guī)：RBC 58/HP，隱血（+）。尿常規(guī)(-)。v要求要求:根據(jù)以上病歷摘要，請(qǐng)將初步診斷及診斷依據(jù)（如有兩個(gè)以上診斷根據(jù)以上病歷摘要，請(qǐng)將初步診斷及診斷依據(jù)（如有兩個(gè)以上診斷，應(yīng)分別列出各自診斷依據(jù)）、鑒別診斷、進(jìn)一步檢查及治療原則寫(xiě)在，應(yīng)分別列出各自診斷依據(jù)）、鑒別診斷、進(jìn)一步檢查及治療原則寫(xiě)在答題紙上。答題紙上。Department of Hematology Department of Hematology The First Affiliated Hos

28、pital of WMCThe First Affiliated Hospital of WMC一、初步診斷及診斷依據(jù) （一）初步診斷 1缺鐵性貧血 2痔 （二）主要診斷依據(jù) 1缺鐵性貧血： （1）慢性起病，出現(xiàn)乏力、面色蒼白、心悸等貧血癥狀，活動(dòng)后加重。 （2）有消化道出血病史：便后有滴血或便紙上帶血。 （3）貧血貌，瞼結(jié)膜和口唇蒼白，心率快，心尖部2/6級(jí)收縮期吹風(fēng)樣雜音。 （4）血常規(guī)檢查符合小細(xì)胞低色素性貧血，糞隱血陽(yáng)性。 2.痔： （1）中年男性，職業(yè)有長(zhǎng)期坐位工作史。 （2）臨床有大便后滴血及便紙上帶血表現(xiàn)，無(wú)胃腸疾病和肝病史。 （3）糞鏡檢有紅細(xì)胞，隱血陽(yáng)性。 Departmen

29、t of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC二、鑒別診斷 1直、結(jié)腸腫瘤 2慢性病性貧血 3鐵粒幼細(xì)胞貧血 三、進(jìn)一步檢查 1血清鐵、鐵蛋白、總鐵結(jié)合力測(cè)定。 2骨髓檢查和鐵染色。 3血清癌胚抗原（CEA）檢查。 4肛門(mén)指診。 5必要時(shí)行直、結(jié)腸內(nèi)鏡檢查。 四、治療原則 1補(bǔ)充鐵劑。 2祛除病因，治療痔。 Department of Hematology Department of Hematology The F

30、irst Affiliated Hospital of WMCThe First Affiliated Hospital of WMC2022-3-1446病例2v男性，42歲，干部。v主訴：乏力、面色蒼白伴濃茶樣尿1月，加重1周。v現(xiàn)病史：1月前因精神郁悶每日飲白酒約1斤后出現(xiàn)乏力、面色蒼白并逐漸加重，1周前出現(xiàn)上二樓即感心悸、偶有耳鳴，無(wú)視物模糊。偶有陣發(fā)性腹部絞痛，無(wú)返酸、噯氣，無(wú)柏油樣便。每日尿色加深，呈濃茶樣，無(wú)醬油樣尿。無(wú)發(fā)熱、畏寒、寒顫、無(wú)腰部疼痛。無(wú)牙血、鼻衄，無(wú)皮膚瘀點(diǎn)瘀斑。無(wú)全身骨關(guān)節(jié)疼痛。v體檢：P 110bpm，重度貧血貌，顏面蒼黃，鞏膜輕度黃染，淺表淋巴結(jié)無(wú)腫大，胸骨

31、無(wú)壓痛。雙肺呼吸音清，律齊，心尖區(qū)/收縮期吹風(fēng)樣雜音；中下腹部壓痛，肝脾肋下未及。Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC病例特征v中年男性v起病隱襲，病程1月v發(fā)病前有飲酒史，既往體健，無(wú)服藥史v貧血：缺氧癥狀、貧血貌、皮膚蒼黃、竇速、心尖區(qū)雜音v黃染：鞏膜黃染、濃茶樣尿v腹痛伴中下腹壓痛2022-3-1447Department of Hematology Department of He

32、matology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC診斷第一步v是否貧血？貧血的程度？v除了貧血還有什么表現(xiàn)？皮膚黃染、濃茶樣尿腹痛v下一步的實(shí)驗(yàn)室檢查？48Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC2022-3-1449實(shí)驗(yàn)室檢查vRBC 2.5 Hb 65g/L HCT 0.19 R

33、DW 0.21vRET 0.18vWBC 5 109/L N 0.70 L 0.26 M 0.04 BPC450 109/Lv 血常規(guī)的特點(diǎn)：MCV=76fL MCH=26pg MCHC=34%Ret#=450109/L校正RET=7.6%RPI=3.4小細(xì)胞正色素性貧血增生性貧血紅細(xì)胞大小不均血小板增多紅細(xì)胞形態(tài)偏小，見(jiàn)少量球形紅細(xì)胞，嗜堿點(diǎn)彩紅細(xì)胞易見(jiàn)Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WM

34、C實(shí)驗(yàn)室檢查vLDH 350U/LvTB 45mol/L DB 7 mol/L ALT、AST、ALB、TP正常 v尿膽原（+）尿膽紅素（-）v黃疸的特點(diǎn)：肝細(xì)胞性黃疸阻塞性黃疸溶血性黃疸50知識(shí)點(diǎn)：溶血性貧血的診斷從先確定存在溶血開(kāi)始，按溶血部位進(jìn)一步判斷病因Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC本例的鑒別診斷小細(xì)胞性貧血小細(xì)胞性貧血v缺鐵性貧血v慢性病性貧血v地中海貧血v鐵粒幼細(xì)胞貧血溶

35、血性貧血溶血性貧血v獲得性免疫性非免疫性v先天性膜異常酶異常血紅蛋白異常51腹腹痛痛v急性血管內(nèi)溶血v腸道病變下一步要做的事情？病史和體檢溶血試驗(yàn)、鐵指數(shù)診斷思維：患者存在多個(gè)主要臨床表現(xiàn)特點(diǎn)時(shí)可以從最容易鑒別的特點(diǎn)入手得出初步結(jié)論，再用該結(jié)論解釋其他的臨床特點(diǎn)；也可綜合多個(gè)特點(diǎn)進(jìn)行鑒別。一個(gè)原則就是盡可能用“一元論”來(lái)診斷。Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC進(jìn)一步的實(shí)驗(yàn)室檢查v鐵蛋白

36、1046 ug/Lv證實(shí)溶血的其他實(shí)驗(yàn)：Coombs (-)、游離血紅蛋白、結(jié)合珠蛋白正常、尿Rous試驗(yàn)(-)B超：肝臟正常，脾臟增厚52結(jié)合小細(xì)胞性貧血，提示鐵利用障礙Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC補(bǔ)充病史和體檢v病史：飲酒的方法和器具v體檢53鉛線：以門(mén)齒、尖齒及第一臼齒的齒齦邊緣多見(jiàn)Department of Hematology Department of Hematolo

37、gy The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC血鉛含量v225g/Lv鉛中毒國(guó)際血鉛標(biāo)準(zhǔn)100g/Lv世界發(fā)達(dá)國(guó)家兒童血鉛60g/L為相對(duì)安全v兒童鉛中毒的分級(jí)100199g/L：血紅素代謝受影響，神經(jīng)傳導(dǎo)速度下降200499g/L：鐵鋅鈣代謝受影響，出現(xiàn)缺鈣、缺鋅、血紅蛋白合成障礙，可有免疫力低下、學(xué)習(xí)困難、注意力不集中、智商水平下降或體格生長(zhǎng)遲緩等癥狀500699g/L：可出現(xiàn)性格多變、易激怒、多動(dòng)癥、攻擊性行為、運(yùn)動(dòng)失調(diào)、視力和聽(tīng)力下降、不明原因腹痛、貧血和心律失常等中毒癥狀；700g

38、/L：可導(dǎo)致腎功能損害、鉛性腦?。^痛、驚厥、昏迷等）甚至死亡。54Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMC本例的診斷v亞急性鉛中毒溶血性貧血55Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCv男性

39、，男性，32歲，頭暈、乏力伴出血傾向半年，加重歲，頭暈、乏力伴出血傾向半年，加重1周周患者于半年前無(wú)誘因出現(xiàn)頭暈、乏力，伴雙下肢皮膚出血點(diǎn)，刷牙后牙齦出患者于半年前無(wú)誘因出現(xiàn)頭暈、乏力，伴雙下肢皮膚出血點(diǎn)，刷牙后牙齦出血，無(wú)鼻衄、黑便，無(wú)發(fā)熱、咳嗽、咳痰，無(wú)關(guān)節(jié)疼痛，在當(dāng)?shù)蒯t(yī)院予中藥血，無(wú)鼻衄、黑便，無(wú)發(fā)熱、咳嗽、咳痰，無(wú)關(guān)節(jié)疼痛，在當(dāng)?shù)蒯t(yī)院予中藥未見(jiàn)明顯好轉(zhuǎn)，未見(jiàn)明顯好轉(zhuǎn)，1周來(lái)上述癥狀加重。病來(lái)二便正常，進(jìn)食好，無(wú)挑食和偏食周來(lái)上述癥狀加重。病來(lái)二便正常，進(jìn)食好，無(wú)挑食和偏食，無(wú)醬油色尿，睡眠可，體重?zé)o變化。，無(wú)醬油色尿，睡眠可，體重?zé)o變化。v既往體健，無(wú)放射線和毒物接觸史，無(wú)藥敏史。既往

40、體健，無(wú)放射線和毒物接觸史，無(wú)藥敏史。v查體：查體：T37，P77次次/分，分，R20次次/分，分，BP110/70mmHg，貧血貌，雙下肢散在，貧血貌，雙下肢散在出血點(diǎn)，淺表淋巴結(jié)未觸及，鞏膜不黃，舌乳頭正常，胸骨無(wú)壓痛，心肺無(wú)出血點(diǎn)，淺表淋巴結(jié)未觸及，鞏膜不黃，舌乳頭正常，胸骨無(wú)壓痛，心肺無(wú)異常，肝脾未觸及，下肢不腫。異常，肝脾未觸及，下肢不腫。v化驗(yàn)：化驗(yàn)：Hb45g/L,RBC1.51012/L,網(wǎng)織紅細(xì)胞網(wǎng)織紅細(xì)胞0.1%,WBC3.0109/L, 分類(lèi)：分類(lèi)：中性分葉中性分葉30%，淋巴，淋巴65%，單核，單核5%，PLT 35109/L，中性粒細(xì)胞堿性磷酸，中性粒細(xì)胞堿性磷酸酶酶

41、(NAP)陽(yáng)性率陽(yáng)性率80%，積分，積分200分，血清鐵蛋白分，血清鐵蛋白210g/L，血清鐵，血清鐵170g /dl, 總總鐵結(jié)合力鐵結(jié)合力280g /dl，尿常規(guī)，尿常規(guī)(-),尿尿Rous試驗(yàn)陰性。試驗(yàn)陰性。問(wèn)題：?jiǎn)栴}：v你認(rèn)為該患者的初步診斷是什么？診斷依據(jù)？你認(rèn)為該患者的初步診斷是什么？診斷依據(jù)？v需要同哪些疾病進(jìn)行鑒別？需要同哪些疾病進(jìn)行鑒別？v還需要完善哪些檢查來(lái)明確診斷？還需要完善哪些檢查來(lái)明確診斷？v該病例的應(yīng)如何治療？該病例的應(yīng)如何治療？Department of Hematology Department of Hematology The First Affiliate

42、d Hospital of WMCThe First Affiliated Hospital of WMCv1、你認(rèn)為該患者的初步診斷是什么？診斷依據(jù)？v初步診斷 全血細(xì)胞減少：慢性再生障礙性貧血可能性大 v診斷依據(jù) 病史：半年多貧血癥狀和出血表現(xiàn) 體征：貧血貌，雙下肢出血點(diǎn)，肝脾不大 血象：三系減少，網(wǎng)織紅細(xì)胞減低，白細(xì)胞分類(lèi)中淋巴細(xì)胞比例增高 NAP陽(yáng)性率和積分均高于正常，血清鐵蛋白和血清鐵增高，而總鐵結(jié)合力降低，尿Rous試驗(yàn)陰性 2.5分Department of Hematology Department of Hematology The First Affiliated Hospital of WMCThe First Affiliated Hospital of WMCv2、需要和那些疾病進(jìn)行鑒別 v骨髓增生異常綜合征(MDS) MDS的某些亞型有全血細(xì)胞減少，網(wǎng)織紅細(xì)胞有時(shí)不高甚至降低，骨髓也可低增生，這些易與AA混淆。但病態(tài)造血現(xiàn)象，原始細(xì)胞比例增高，造血祖細(xì)胞培養(yǎng)集簇增多集落減少，染色體