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病历摘要男性,40岁,住院号121222,于1989年6月15日入院。患者近半年来不定时上腹至脐周围痛伴畏寒、发热,呈不规则热型,无恶心、呕吐,无腹泻,无脓血便。入院前三天无明显诱因出现上腹痛,解黑便伴眩晕、乏力、出汗转入我院。体检:贫血貌,巩膜无黄染,全身浅表淋巴结未及,心肺(-)。腹软,上腹稍压痛,腹未及包块,肝肋下2.0cm,质中,墨菲氏征(-),脾肋下1.0cm,移浊(-),两下肢不肿.实验室检查:Hb65～70g/L,RBC2.24～2.40×10~(12)/L,WBC4～5.5×10~9/L,N:70～80%,
Medical summary Male, 40 years old, hospital ad 121222, was admitted on June 15, 1989. Patients with irregular changes in the past six months from the upper abdomen to the umbilical pain associated with chills, fever, irregular heat type, no nausea, vomiting, no diarrhea, no purulent blood. Three days before admission no obvious incentive to upper abdominal pain, black solution with dizziness, fatigue, sweating transferred to our hospital. Physical examination: anemia, scleral no yellow dye, systemic superficial lymph nodes, cardiopulmonary (-). Abdominal soft, abdominal a little tenderness, abdominal and mass, liver ribs 2.0cm, quality, Murphy’s sign (-), spleen ribs 1.0cm, moving turbid (-), two lower extremity is not swollen. Check: Hb65 ~ 70g / L, RBC2.24 ~ 2.40 × 10 ~ (12) / L, WBC4 ~ 5.5 × 10 ~ 9/L, N: 70 ~ 80%