病历摘要男患,戴某某,25岁,住院号1209。因腹痛、腹泻、血便一周于1990年6月18日入院。患者于一周前无任何诱因出现阵发性腹痛,以右下腹为主,伴腹泻每月4～6次。为脓血便、水样便或褐色便交替出现,伴里急后重,无发热,无恶心呕吐。否认不洁饮食。患者于5年前有不规则腹痛、腹泻、血便史。一般2～3天停止,未作任何检查。家族中无类似病者。先后在院外按“急性胃肠炎”,“急性菌痢”治疗无效,于1990年6月18日转入本院。入院检查:T36.5℃,P72次/分,Bp16/10kPa.神清,皮肤无黄染及出血点,全身浅表淋巴结无肿大,心肺未发现异常。腹部平软有压痛,肠鸣音亢进,脐右侧触及索条状包块,界限不清,无明 Medical summary Male suffering, Dai Moumou, 25 years old, hospital 1209. Due to abdominal pain, diarrhea, bloody stool a week in June 18, 1990 admission. Patients with paroxysmal abdominal pain without any cause a week ago, mainly to the right lower quadrant, with diarrhea 4 to 6 times per month. For pus and blood, water or brown will be alternating, with tenesmus, no fever, no nausea and vomiting. Denied unclean diet. 5 years ago, patients had irregular abdominal pain, diarrhea, bloody history. Generally 2 to 3 days to stop, without any check. There are no similar patients in the family. Successively in the hospital according to “acute gastroenteritis”, “acute bacillary dysentery” treatment ineffective, in June 18, 1990 transferred to our hospital. Admission examination: T36.5 ℃, P72 times / min, Bp16 / 10kPa. God clear, no yellow skin and bleeding points, systemic superficial lymph nodes without swelling, no abnormal heart and lung. Abdomen soft and tenderness, bowel sounds hyperthyroidism, hides on the right side of the umbilical cord, mass, unclear boundaries, no clear