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病历摘要患者(天津市立第二医院住院号14121。病理检查号6103307)男性,29岁,于1961年6月12日因右下腹肿物及疼痛一年而入院。症状出現五个月后,用抗結核药物治疗。疼痛減輕,肿块縮小。于住院前二周,大便每日增至20—30次,粪便稀軟,含粘液。住院前三日,大便中有鲜血。既往健康,无慢性咳嗽或咯血史,亦无痢疾史。体格檢查:慢性病容,消瘦,体温与脉搏正常。无全身及局部淋巴结肿大。心肺正常。腹部柔軟,右髂窝处飽满,可摸到一椭圆形肿物,约8×11厘米大小,边緣清楚,不活动,表面不光滑,质硬。直腸內无肿块。化驗檢查:紅血球323万,血紅蛋白8.7克,白血球11500,中性多核球77％,淋巴球23％,血沉率第一小时108毫米。大便稀,含血及粘液,鏡下检查:有红血球
Patient (Tianjin Second Hospital No. 14121. Pathology No. 6103307) Male, 29 years old, was admitted to the hospital on June 12, 1961 due to a right lower quadrant and pain for one year. Five months after the onset of symptoms, treatment with anti-TB drugs. Pain relief, mass reduction. Two weeks before hospitalization, stool increased to 20-30 times a day, stools thin and soft, with mucus. Three days before admission, there is blood in the stool. Past health, no history of chronic cough or hemoptysis, no history of diarrhea. Physical examination: chronic disease, weight loss, body temperature and pulse normal. No systemic and local lymph nodes. Cardiopulmonary normal. Abdomen soft, full right iliac fossa, can touch an oval tumor, about 8 × 11 cm size, clear edge, inactive, the surface is not smooth, hard. No mass in the rectum. Laboratory tests: 3.23 million red blood cells, hemoglobin 8.7 grams, 11500 white blood cells, 77% neutral multi-nuclear, lymphocytes 23%, erythrocyte sedimentation rate of 108 mm first hour. Thin stool, blood and mucus, microscopic examination: red blood cells