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病历摘要:患者男性59岁,肝区反复隐痛4年,巩膜皮肤黄染半月,干1987年9月28日入院。近4年来肝区隐痛、食欲下降、乏力,1年前开始出现腹胀,院外检查发现肝肿大、腹水、肝功能异常,诊断为“肝炎后肝硬化”。给保肝治疗后症状缓解,近半月来因肝区痛加重、腹胀、巩膜皮肤深度黄染收入院,既往无肝炎及长期服药病史,否认疫水接触史,有20余年饮酒史,每日约半斤。体检:神志清楚、重病容、巩膜皮肤黄染,无肝掌及蜘蛛痣,浅表淋巴结不肿大,心肺无异常,腹部隆起,未见静脉怒张,腹围89cm,腹壁软无压痛,肝肋下3. 0cm,质地中等,表面光滑,有触痛、脾脏未触及,未扪及腹块,腹水征阳性。门诊化验检
Medical records Abstract: Male patients 59 years old, recurrent pain in the liver area for 4 years, scleral skin yellow dye half months, dry September 28, 1987 admission. Hypertension in the liver area in the past 4 years, loss of appetite, fatigue, bloating began 1 year ago, hepatomegaly found outside the hospital, ascites, liver dysfunction, diagnosed as “hepatitis cirrhosis.” To alleviate the symptoms of liver protection, nearly half a month due to increased liver pain, abdominal distension, scleral skin depth yellow dye admission to the hospital, without previous history of hepatitis and long-term medication, history of denial of exposure to water, drinking history of more than 20 years, daily about Half a catty. Physical examination: conscious, seriously ill, scleral skin yellow dye, liver palms and spider nevus, superficial lymph nodes is not enlarged, no abnormal heart and lungs, abdominal bulge, no venous anger, abdominal circumference of 89cm, abdominal soft tenderness, liver Ribs 3. 0cm, medium texture, smooth surface, tenderness, spleen not touched, palpable abdominal mass, ascites sign positive. Outpatient laboratory inspection