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患者,女,63岁,因腹胀、腹痛、纳差、乏力、盗汗1个月,加重7天,于1993年12月12日入院,既往无肺结核等病史。查体:T 37.8℃,P110次/分,R 24次/分,Bp 17.33/10.67kPa。消瘦,贫血貌,皮肤、巩膜无黄染,浅表淋巴结未触及。心肺检查无异常发现,腹部膨隆,弥漫性轻压痛,肝脾未触及,腹部移动性浊音(++)。双下肢无浮肿,神经系统检查无异常。实验室检查:Hb 90h/L,WBC 3.9×10~9/L,N 0.64,L 0.36,ESR 70mm/h。肝功正常,胸片正常,腹水常规为渗出液,B超示腹水。临床诊断:结核性腹膜炎。
The patient, female, aged 63, was admitted to hospital on December 12, 1993 due to abdominal distension, abdominal pain, anorexia, weakness and night sweats. He was exacerbated for 7 days and had no previous history of tuberculosis. Examination: T 37.8 ℃, P110 beats / min, R 24 beats / min, Bp 17.33 / 10.67kPa. Thin, anemic appearance, skin, sclera no yellow dye, superficial lymph nodes not touched. Heart and lung examination showed no abnormalities, bulging abdomen, diffuse mild tenderness, liver and spleen not touched, abdominal dullness (++). No lower extremity edema, nervous system examination no abnormalities. Laboratory tests: Hb 90h / L, WBC 3.9 × 10 ~ 9 / L, N 0.64, L 0.36, ESR 70mm / h. Normal liver function, normal chest, ascites routine exudate, B ultrasound showed ascites. Clinical diagnosis: tuberculous peritonitis.