病历摘要例1:广某某,男、31岁、农民,云南宾川县人,因有上腹部肿块四年余入院。近两年来,大便稀、带粘液,时有血丝;近期感包块变硬,偶有疼痛,但能自行缓解。曾放牧山羊为十余年。查体:T:37.6℃、P:76次/分、R:20次/分、BP:136/70mmHg,一般情况好,心肺无异常,有腋前线肋缘下隐约可见皮肤隆起,该部可触及10×8厘米之肿块、无压痛、表面光滑,质地中等,边界不太清楚,肿块上界入肋缘下,横向轻度移 Case summary 1: Guangmou, male, 31 years old, farmer, Binchuan County, Yunnan Province, because of the upper abdominal mass more than four years admitted to the hospital. In the past two years, thin stools, with mucus, sometimes bloodshot; recent sense of hardening of the package, occasionally pain, but can relieve itself. Have grazed goats for more than ten years. Check the body: T: 37.6 ℃, P: 76 beats / min, R: 20 beats / min, BP: 136 / 70mmHg, generally good, no abnormal heart and lungs, Touched 10 × 8 cm mass, no tenderness, smooth surface, medium texture, the border is not clear, the upper boundary of the tumor into the costal margin, horizontal and light shift