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1病历摘要女,65岁。以右上腹部胀痛不适20d,曾在当地间断诊治效果欠佳,于2010-08-15入住我院。入院时精神、食欲差,体力下降,大小便正常。既往身体健康,经常参加体力劳动。查体:T 36.5℃,P 62次/min,R 25次/min,BP 90/60mm Hg,痛苦面容,消瘦,皮肤干燥,弹性差,颜面及眼睑无水肿,端坐呼吸,口唇发绀,胸廓对称,无畸形,双肺叩诊轻音,双肺呼吸音粗,无干湿性啰音,心尖搏动无弥散,无奇脉,HR62次/min,无杂音,
1 medical record summary female, 65 years old. To the right upper abdomen pain discomfort 20d, had discontinued in the local diagnosis and treatment of poor results, in 2010-08-15 admitted to our hospital. Admission spirit, poor appetite, physical decline, normal urine. Past health, often participate in manual labor. Examination: T 36.5 ℃, P 62 times / min, R 25 times / min, BP 90 / 60mm Hg, painful face, weight loss, dry skin, poor elasticity, no edema on face and eyelids, Symmetrical, no deformity, lungs percussion tone, lung breath sounds thick, no wet and dry rales, apex beat no dispersion, no miraculous, HR62 times / min, no noise,