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病历摘要患者,男性,19岁,住院号83367。于入院前八周因右侧睾丸肿胀,在某医院诊断为副睾结核,并经手术切除。术后11日突然发冷、发热,并感腹胀、气短,经当地医院诊断为结核性胸、腹膜炎,曾自右胸抽出血性胸水约2,000毫升,当时伴有咳嗽及咯痰带血,逐渐消瘦,曾连续排柏油样便四次,经抗结核治疗无效,于1965年4月20日转来我院。入院后病情急剧恶化,并反复排暗红色血便,死亡前便鲜血约1,1000毫升,继之呈朦胧状态,经抢救无效死亡。体检:体温36.5℃,脉搏102次/分,血压100/70mmHg,贫血貌,呈恶病质状态。神志清,浅部淋巴结不肿大,气管左移,胸壁有小出血点,右胸叩诊浊音,呼吸音显著减弱,心左界在左锁骨中线
Patient summary, male, 19 years old, hospital ad 83367. Eight weeks before admission due to the right testicular swelling, in a hospital diagnosis of epididymal tuberculosis and surgical resection. Suddenly on the 11th after the cold, fever, and sense of abdominal distension, shortness of breath, the local hospital diagnosed with tuberculous thoracic and peritonitis, had drawn from the right chest bloody pleural effusion about 2,000 ml, when accompanied by cough and expectoration bloody, and gradually thin , Had a row of asphalt like it four times, the anti-TB treatment ineffective, on April 20, 1965 transferred to our hospital. The condition deteriorated sharply after admission, and repeatedly discharged dark red bloody stool, before the death of about 1,1000 ml of blood, followed by a hazy state, died of ineffective rescue. Physical examination: body temperature 36.5 ℃, pulse 102 beats / min, blood pressure 100 / 70mmHg, anemia appearance, was cachexia state. Consciousness, shallow lymph nodes is not enlarged, the left trachea, chest wall bleeding, right chest percussion dullness, breath sounds significantly weakened, left heart center in the left clavicle