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何××42岁,住院号90904,1980年11月6日入院。停经两个月,阴道不规则少量流血20天,近4天以来左下腹绞痛伴大便感急诊入院。患者七年前,产后第4天,行腹式输卵管结扎术(潘氏法),经过良好,4天拆线,刀口愈合佳,产后10天出院。7年以来月经正常,无腰痛及下腹痛史,现停经两个月,无早孕反应,二便正常。检查:T38℃,P80次/分,BP120/80毫米汞柱,急性痛苦病容,轻度贫血貌,心肺正常,腹部略膨隆,下腹压痛,反跳痛明显,移动性浊音阴性。
Ho × × 42 years old, hospital number 90904, November 6, 1980 admission. Menopause two months, vaginal irregular small amount of bleeding for 20 days, nearly 4 days since the left lower quadrant colic with stool flu emergency admission. Patients seven years ago, the first 4 days postpartum, abdominal tubal ligation (Pan’s method), after a good, 4 days stitches, good incision, 10 days postpartum discharge. Normal menstruation for 7 years, no back pain and abdominal pain history, now menopause two months, no early pregnancy reaction, two will be normal. Check: T38 ℃, P80 beats / min, BP120 / 80 mm Hg, acute pain, mild anemia appearance, normal heart and lungs, slightly bulging abdomen, abdominal tenderness, rebound tenderness obvious, shifting voiced negative.