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患者张××,男,54岁,农民,陕西蒲城人,住院号13081号。1973年2月25日入院。病历摘要: 于入院前三个月开始头昏、乏力、食欲减退,眼及皮肤渐黄,一个月后伴发冷、发烧,约五、六日发作一次,发烧时右胁下疼痛较剧,似钝痛,向背部及右肩部放散,服止痛片可缓解,当时未注意,至入院前一月,发现右胁下有一包块,约鸡蛋大,压痛明显,但较软,上述症状也加重,且伴恶心无呕吐,小便黑红色,大便如常,皮肤发痒,在当地以肝炎治疗稍好转,入院前二十多日,症状反复加重,
Patient Zhang × ×, male, 54 years old, farmer, Pucheng, Shaanxi, hospital number 13081. February 25, 1973 admission. Medical records Summary: Three months before admission dizziness, fatigue, loss of appetite, eyes and skin gradually yellow, one month after with cold, fever, about five or six attack, fever when the right flank pain more drama, Like dull pain, to the back and right shoulder, dissipated, clothes, painkillers can ease, did not pay attention at that time, to January before admission and found that there is a mass under the right flank, about large eggs, tenderness obvious, but softer, the symptoms Aggravating, and with nausea and vomiting, urine black and red, normal stool, itchy skin, hepatitis treatment in the local slightly better, more than 20 days before admission, the symptoms repeatedly increased,