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患者,男,34岁,住院号157416。因腹胀、腹痛3月,加重10天于1997年1月7日入院。该患者3月前无诱因出现腹胀,伴有腹痛,开始以脐周为主,逐渐发展至全腹,呈阵发性钝痛,无放射痛。大便习惯改变,每日解糊状软便2～4次,无规律,无脓血及里急后重感。10天前症状加重.3月来食欲低,时有夜间盗汗,体重下降15kg。在地方医院做腹部B超示腹水,肝胆CT、全消化道钡透未见器质性病变,按肠结核治疗症状无好转。入院查体:神志清楚,慢性病容,精神差,消瘦,皮肤无黄染,未见血管蛛、出血点,浅表淋巴结未扪及肿大。心肺未见异常。腹部膨隆、柔软,呈揉面感,全腹压痛,无反跳痛,肝脾肋缘下未触及,未扪及包块,移动性浊音阳性,肠鸣音2
Patient, male, 34 years old, hospital number 157416. Due to bloating, abdominal pain in March, increased 10 days in January 7, 1997 admission. The patient had no evidence of abdominal distension 3 months ago, accompanied by abdominal pain, began to the umbilical week, and gradually developed to the whole abdomen, paroxysmal dull pain, no radiating pain. Changes in bowel habits, daily solution of paste loose stool 2 to 4 times, no law, no abscess and tenesmus heavy sense. Ten days ago, the symptoms worsened .3 months, low appetite, night sweats, weight loss 15kg. Abdomen in the local hospital to do abdominal B-ascites, hepatobiliary CT, barium-free digestive tract no organic disease, no improvement in symptoms of tuberculosis. Admission examination: Conscious, chronic illness, poor health, weight loss, skin yellow dye, no vascular spider, bleeding point, superficial lymph nodes palpable and enlarged. Heart and lung no abnormalities. Abdominal bulge, soft, was kneaded, full abdominal tenderness, no rebound tenderness, liver and spleen under the edge of the ribs have not touched, palpable mass, mobile dullness positive, bowel sounds 2