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病历摘要患者女,50岁,住院号285433。三个月前患者因发热、腹痛到某医院就诊,疑阑尾炎、腹膜炎,抗炎治疗20余日,不见好转。后又因贫血(Hb6g)在某医院行骨穿,诊断为缺铁性贫血,虽用升血素治疗仍不见好转。86年1月30日来我院妇科,门诊以盆腔肿物继发感染,肾区肿物待查,继发贫血收入院。检查:营养中等,痛苦面容,面色苍白。T38.4℃,P120次/分,Bp90/70mmHg。心肺正常,腹略膨隆,肝脾触不清。左上腹可触及边界不清的肿块,约手拳大,较硬,无压痛,叩之发浊,无活动性。下腹部可触及新生儿头大肿物,边界不清。下腹部肌紧张,有压痛及反跳痛,叩诊鼓实相间,无移动浊音。妇科检查:外阴阴道正常,宫颈光滑,宫体后倾偏左,大小
Patient summary Female patient, 50 years old, hospital number 285433. Three months ago due to fever, abdominal pain to a hospital, suspected appendicitis, peritonitis, anti-inflammatory treatment for more than 20 days, did not improve. Later, due to anemia (Hb6g) in a hospital for bone wear, diagnosis of iron deficiency anemia, although the treatment with hemin did not improve. January 30, 2006 to our hospital gynecology, outpatient pelvic tumor secondary infection, kidney tumor to be investigated, secondary anemia income hospital. Check: medium nutrition, painful face, pale. T38.4 ° C, P120 bpm, Bp90 / 70 mmHg. Cardiopulmonary normal, abdominal bulging, liver and spleen touch unclear. The upper left abdomen can touch unclear mass of the lumps, about hand fist large, hard, no tenderness, knocking turbid, no activity. Lower abdomen can reach the newborn head large tumor, the border is unclear. Lower abdominal muscle tension, tenderness and rebound tenderness, percussion drum phase, no movement dullness. Gynecological examination: vulva and vaginal normal, smooth cervix, left and right behind the palace body size