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ID:43512014
大小:1.08 MB
页数:17页
时间:2019-10-09
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1、CASEREPORTDepartmentofGeneralSurgerMay12th,2016MedicalRecordsforAdmissionName:Sex:femaleAge:31RegistrationNo.:Dateofadmission:ChiefcompliantTwomonthsafterappendicectomy;RecurrentabdominalpainassociatedwithfeverforonemonthPresenthistory1rightventralabdominalpa
2、in,2monthsagoappendicectomyinHongkongabdominalpainassociatedwithfeverforonemonthmaximumbodytemperatureupto38.9℃TherearenosimilardiseasesinhisfamilyFamilyHistoryrightlowabdominalpainstenderness(+)、Reboundtenderness(+);PhysicalExaminationBloodroutine21-Apr29-Ap
3、r4-May8-May10-MayWBC14.3712.310.3414.619.42X10~9/L3.5--9.5NEUT%82.483.385.588.784.1%40--75%RBC4.824.84.744.494.36X10~12/L3.8--5.1HB110114112106103g/L115--150g/LPLT398373389413370X10~9/L125--350X10~9/LurineroutineLEU3+-UWBC44.3/ul0--23/ulURBC8.4/ul0--18/ulEC4.
4、8/ul0--3/ulBXBGBSY8/HPF0--5个/HPHXBGBSY1.5/HPF0--3个/HPF4/21coagulationfunctionPT15.3s10--14sINR1.33APTT37.9s23--35sTT18.2s14--21sFBG3.72g/L1.7--4.5g/LLiverfunctiontest4/21TP67.5g/L65--85g/LALB34.1g/L40--55g/LALP51.8U/L35--100U/LGGT23.2U/L7--45U/LALT6.9U/L7--40
5、U/LAST12U/L13--35U/LTumormarker4/7AFP11.2ng/ml0.89--8.78ng/mlCEA0.48ng/ml0--10ng/mlCA12522.1U/mL0--35U/mLCA1535.5U/mL0--28U/mLCA1997.5U/mL0--37U/mLLABFINDINGSImageologicalexamination:1、肝胆胰脾、双肾输尿管、膀胱、子宫、附件无殊。2、右下腹非均质性包块。ESR24mm/h0--20mm/hCTDescription:右侧回盲部见斑片
6、状软组织密度影及条索影,边缘毛糙,约29x43mm,增强明显不均匀强化,内低密度坏死去无强化,右侧腹壁下见略不规则环形强化影。阑尾区少量积气,见高密度结石夹留置,呈术后改变,周围见多个稍大淋巴结,增强明显强化。CT1、阑尾术后改变并回盲部、阑尾周围脓肿,建议治疗后复查;2、阑尾周围多发淋巴结影;3、肝右叶后上段不典型小血管瘤多考虑,随访;4、阴道穹窿部少量积液,请结合临床考虑。Diagnosis1.appendicitisafterappendectomy2.AbdominalAbscessDiscusion:f
7、urthertreatment?
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