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病历摘要:患者21岁,女,住院号70620,因发热、腹胀、腹痛2月,突然剧痛2天,于1989年1月2日以消化道穿孔,腹膜炎收院。既往健康,现闭经6月,一孕一产。查体:体温38.3℃,脉搏110次/分,血压10.7/8.0kPa急病容,全身表浅淋巴结不肿大。腹隆,肝脾不大,下腹部可触及肿物达脐上1指,质硕,全腹部肌紧张压痛及反跳痛,移动性浊音(+)。
Medical record Summary: The patient was 21 years old, female, hospital number 70620, due to fever, bloating, abdominal pain in February, a sudden severe pain for 2 days, January 2, 1989 to digestive tract perforation, peritonitis admission. Past health, now amenorrhea in June, a pregnancy and a production. Physical examination: body temperature 38.3 ℃, pulse 110 beats / min, blood pressure 10.7 / 8.0kPa emergency capacity, systemic superficial lymph nodes are not enlarged. Abdominal long, small spleen and liver, lower abdomen palpable mass up to 1 umbilical, quality, full abdominal tenderness and rebound tenderness, mobility dullness (+).