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病历摘要 患者,女,9岁,住院号156382。主因乏力纳差40天,腹部胀痛1月于91年7月30日入院。入院前40天起感乏力,食欲不振,发热,多汗,10天后自觉热退,但仍感乏力纳差,且出现中上腹部胀痛,并发现腹部有一包块,质硬,触痛,半月后到当地医院诊治不见好转,肿物逐渐长大,遂入我院。查体:体温36.3℃,脉搏90次/分,呼吸26次/分,血压13/9kpa。一般情况尚好。神清,颜面红润,皮肤,粘膜无黄染及出血点,颌下及颈部可触及0.5×0.5cm大小之淋巴结数个,无触痛;心肺叩听未见异常。腹P部膨隆,无腹壁静脉曲张,腹部可触及巨大包块,几乎遍及全腹,上界与肋弓相连,右侧下界可达骨盆,左侧下界在左肋缘下5cm处,肿块表面凹凸不平,质硬有压痛,无腹水征,双下肢无浮肿,实验室检查:Hb115g/L WBC14.3×10~9/L No.80L0.20血小板551×10~9/L。肝功能:TTT10uHBsAg1:32廿,总蛋白10g/L,白与
Medical record summary Patient, female, 9 years old, hospital number 156,382. The main cause of fatigue was an apnea for 40 days. Abdominal pain was admitted to hospital on July 30, 91 in January. 40 days before admission, she felt fatigue, lack of appetite, fever, sweating, and felt feverishly retired after 10 days. However, she still felt weak and tired, and had a pain in the middle and upper abdomen. He found that there was a mass in the abdomen, which was hard and tender. Half a month later, the diagnosis and treatment at the local hospital did not improve. The tumor gradually grew up and fell into our hospital. Physical examination: body temperature 36.3 °C, pulse 90 beats / min, breathing 26 beats / min, blood pressure 13/9kpa. The general situation is still good. Shen Qing, facial ruddy, skin and mucous membranes without yellowing and bleeding, submandibular and neck can touch several 0.5×0.5cm lymph nodes, no tenderness; cardiopulmonary hearing was not abnormal. Abdominal P bulging, no abdominal varicose veins, abdomen palpable huge mass, almost throughout the abdomen, the upper bound with the rib arch, the right lower border up to the pelvis, the left lower border in the left costal 5cm, the surface of the tumor bump Uneven, hard and tender, no ascites, no edema in both lower limbs, laboratory tests: Hb115g/L WBC14.3×10~9/L No.80L0.20 Platelets 551×10~9/L. Liver function: TTT10uHBsAg1: 32 廿, total protein 10g/L, white and