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病历摘要:患者男性,60岁。因肛门区疼痛2年,排便困难半年,加重一个月,于1979年6月18日入院。患者于1977年3月感觉肛门区偶发针刺样疼痛,曾被诊断为内痔。肛门区疼痛逐渐加重,1978年9月做直肠指检发现直肠前壁有肿块,但直肠窥镜检查失败(插不进),诊断前列腺肥大,服已烯雌酚治疗三个月无效。1979年1月出现排便困难,大便变细,至入院前一个月肛门疼痛加剧,排便更困难,需服泻药才能解出,但无粘液、脓血便,同时出现排尿困难、排尿中断及尿痛现象,但无尿急、尿频、尿血。诊断前列腺肿瘤入院。体查:T37.4℃,P82次/分,R20次/分,血压150/90mmHg。发育营养可,全身浅表淋巴结无肿大,皮肤巩膜无黄染,心肺正常,腹部未扪及肿块,
Medical record summary: The patient is male, 60 years old. Because of the pain in the anal area for 2 years, the defecation was difficult for six months, an increase of one month, and was admitted on June 18, 1979. The patient experienced occasional acupuncture-like pain in the anal area in March 1977 and was diagnosed with internal hemorrhoids. Pain in the anal area gradually worsened. In September 1978, digital rectal examination revealed a mass in the anterior rectal wall. However, rectal examination failed (not inserted). Diagnosis of prostatic hypertrophy and treatment with diethylstilbestrol was not effective for three months. In January 1979, defecation was difficult, and the stool became thinner. One month before admission, the pain in the anal intensified. Defecation was more difficult. It was necessary to take laxatives to resolve it. However, there was no mucous, pus, and bloody stool. Difficulty of urination, interruption of urination, and dysuria were also observed. , but no urgency, frequent urination, hematuria. Diagnosis of prostate tumor admission. Physical examination: T37.4°C, P82 beats/min, R20 beats/min, blood pressure 150/90 mmHg. Development of nutrition can be, no enlargement of superficial lymph nodes, no yellow skin sclera, normal heart and lung, abdominal hernia and lump,