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病历摘要例1:男,59岁。因不规则发热,乏力3年,盗汗,消瘦伴左侧腰背部疼痛月余,于1988年11月住院。查体:全身浅表淋巴结不肿大,腹部稍膨隆,左上腹可扪及肿大的脾脏,平脐,压痛,腹水征(-)。B 超示脾内有约10×7×5cm 大小的实质性占位。入院诊断:脾脏肿瘤。予以剖腹探查,见脾脏内肿块约8×7×5cm,表面不光滑,呈灰白色,实质性。脾门周围见数个肿大淋巴结,最大的如蚕豆大小。作脾脏及肿大淋巴结切除。病理诊断。脾恶性淋巴瘤(ML)(B 系-小无裂细胞型)。术后予以CHOP 方案化疗6个周期,中间夹以腹部放疗60Gy。临床治愈出院。至今健在。例2:男,55岁。因突然发作左侧腹痛,深呼吸时加重一小时,于1989年8月急诊入院。查体:全身浅表淋巴结不肿大。腹部平坦,左上腹明显压痛,脾肋下5cm。B 超示脾内有9×9cm 的实质性占位。入院诊断:脾脏占位性病变。予以剖腹探查,见脾脏明显增大,作脾切除术,发现肿块呈实质性,约11×9×8cm 大小,呈结节状,灰白色。病理诊断:脾脏恶性淋巴瘤(B 系-裂无裂混合细胞型)。予以CHOP方案化疗6个周期,中间夹以腹部放疗40 Gy。临床
Medical Record Abstract Example 1: Male, 59 years old. Due to irregular fever, fatigue for 3 years, night sweats, weight loss with more than one month left and back pain, was hospitalized in November 1988. Physical examination: The superficial lymph nodes of the body are not swollen, the abdomen is slightly bulging, the left upper abdomen can be paralyzed and the enlarged spleen, flat umbilicus, tenderness, and ascites sign (-). B shows that the spleen has a substantial size of about 10×7×5 cm. Admission diagnosis: Splenic tumors. To be exploratory laparotomy, see the spleen mass about 8 × 7 × 5cm, the surface is not smooth, grayish, substantive. Several enlarged lymph nodes are seen around the spleen gate, the largest being the size of broad beans. Spleen and enlarged lymph node resection. Pathological diagnosis. Splenic Malignant Lymphoma (ML) (B-system - small non-cleaved cell type). After 6 cycles of chemotherapy with CHOP regimen, 60 Gy of abdominal radiotherapy was placed in the middle. Clinical cure was discharged. He is still alive. Example 2: Male, 55 years old. He was admitted to the hospital in an emergency in August 1989 due to sudden onset of abdominal pain on the left side and an hour of deep breathing. Physical examination: The superficial lymph nodes are not swollen. The abdomen is flat and the left upper abdomen is markedly tender. The spleen is 5 cm below the ribs. B super shows that the spleen has a substantial occupancy of 9×9 cm. Admission diagnosis: splenic lesions. To be exploratory laparotomy, see the spleen significantly increased, for splenectomy, found that the mass was substantial, about 11 × 9 × 8cm size, nodular, grayish white. Pathological diagnosis: malignant lymphoma of the spleen (B-segmentation and fissure-free mixed cell type). The CHOP regimen was given 6 cycles of chemotherapy with 40 Gy of abdominal radiotherapy. clinical