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患者,男,48岁,因“反复腹痛,腹胀1个月,加重1d”急诊入院。既往无心脏病、高血压病、糖尿病及疫区居住病史。查体:T 38.6℃,P 160~170次/min,BP 60/35 mmHg(1 mmHg=0.133kPa)。烦躁,贫血貌,腹肌紧张,全腹压痛明显,反跳痛阳性。辅助检查:血常规:Hgb 76g/L,WBC 2.55×109/L,动脉血乳酸8.8 mmol/L;血气:pH 7.32,PO266mmHg,K 3.2mmol/L;腹部增强CT示:右侧腹膜后间隙见积液、积气,升结肠壁局部似不连续。初步诊断:肠穿孔,感染性休克。
Patients, male, 48 years old, because of “repeated abdominal pain, bloating 1 month, increased 1d ” emergency admission. Past no heart disease, hypertension, diabetes and epidemic history of residency. Examination: T 38.6 ℃, P 160 ~ 170 times / min, BP 60/35 mmHg (1 mmHg = 0.133kPa). Irritability, anemia appearance, abdominal muscle tension, full abdominal tenderness, rebound pain positive. Auxiliary examination: blood: Hgb 76g / L, WBC 2.55 × 109 / L, arterial blood lactate 8.8 mmol / L; blood gas: pH 7.32, PO266mmHg, K 3.2mmol / L; abdominal enhanced CT showed: right retroperitoneal space see Effusion, gas, ascending colon wall local seems not continuous. Preliminary diagnosis: intestinal perforation, septic shock.