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1 病历摘要患者,男,26岁,主因发作性腹痛3个月,四肢瘫痪2天入院。自诉3天前劳累后腹部阵发性剧烈疼痛,恶心、呕吐胃内容物,输液治疗后缓解,共发作4次。5天前腹痛再发,低热、恶心、呕吐、大便秘结,以“急腹症”收住外科保守治疗,腹痛渐缓解;2天前因四肢瘫痪转入内科。查体:T37.2℃P80次/minR16次/minBP16/10KPa神志清,心肺无异常,腹软,无压痛反跳痛及包块,肝脾未触及,四肢肌力Ⅲ级,无感觉障碍,膝腱反射减弱,病理反射未引出。血Hb12.66/LWBC11.0×10~9/LN0.74L0.26PLT160×10~9/L,尿10A正常,肝功能正常,
1 patient summary of the patient, male, 26 years old, mainly due to the onset of abdominal pain for 3 months, four days paralyzed hospitalized. Self-indictment 3 days ago tired belly paroxysmal severe pain, nausea, vomiting stomach contents, relieve infusion therapy, a total of 4 times. 5 days ago, recurrent abdominal pain, fever, nausea, vomiting, constipation, with “acute abdomen,” admitted to surgical conservative treatment, abdominal pain gradually ease; 2 days ago due to paralysis of the limbs into the internal medicine. Examination: T37.2 ℃ P80 times / minR16 times / minBP16 / 10KPa Consciousness, no abnormal heart and lung, abdominal soft, no tenderness and rebound tenderness and mass, liver and spleen not touched, muscle strength Ⅲ grade, no sensory disturbances, Knee tendon reflex decreased, pathological reflex did not lead. Blood Hb12.66 / LWBC11.0 × 10 ~ 9 / LN0.74L0.26PLT160 × 10 ~ 9 / L, urine 10A normal, normal liver function,