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1病历摘要患者,36岁。因右中下腹持续性疼痛2天,于2002年12月20日入院。查体:T、P、R、BP均正常;心肺(一);腹平坦,软,右中下腹压痛,反跳痛阳性;肝、脾肋下未触及;移动性浊音(一),肠鸣音正常。妇科检查:外阴已婚经产式,阴道通畅,宫颈光滑、肥大,有举痛,摆痛;子宫后位,大小正常,压痛;双侧附件压痛,以右侧为甚,未扪及包块,后穹窿触痛,不丰满;白带臭,有异味。血常规:Hb115g/L,RBC4.1×1012/L,WBC4.5×109/L,N0.67,L0.33,BPC97×109/L,尿HCG弱阳性,妇科彩超示子宫附件未见异常。月经正常;足月产2次,早产1次,现有1子1女,末次妊娠1989年5月,末次妊娠产1男活婴,13年前行女性绝育术。入院诊断:①急性盆腔炎;②急
1 patient summary patient, 36 years old. Due to persistent pain in the right lower abdomen for 2 days, on December 20, 2002 admission. Physical examination: T, P, R, BP are normal; cardiopulmonary (a); abdominal flat, soft, right lower abdomen tenderness, rebound tenderness positive; liver, spleen ribs were not touched; Normal sound. Gynecological examination: genital Married by type, vaginal patency, cervical smooth, hypertrophy, pain, pain; posterior uterine position, normal size, tenderness; bilateral attachment tenderness, to the right is even, not palpable mass , After the dome tenderness, not full; leucorrhea smell, smell. Blood routine: Hb115g / L, RBC4.1 × 1012 / L, WBC4.5 × 109 / L, N0.67, L0.33, BPC97 × 109 / L, urinary HCG weak positive, gynecological color ultrasound showed no abnormalities in the uterus attachment . Normal menstruation; full-term 2 times, 1 premature birth, the existing 1 child and 1 woman, the last pregnancy in May 1989, the last pregnancy, 1 male live births, 13 years before the female sterilization. Admission diagnosis: ① acute pelvic inflammatory disease; ② acute