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患者,男性,36岁。缘于2年前无明显诱因,感右上腹隐痛,但不久即缓解,本次发病于7天前,自觉右上腹疼痛较前加重,伴皮肤巩膜黄染,尿呈脓茶样,3天来大便呈陶土样,低烧,经抗感染治疗效果不佳,为明确诊断来我院就诊。查体:体温37.8度,血压12/6KPa,一般情况尚可,神清,急性痛苦病容,全身皮肤及巩膜黄染,上腹较饱满,右侧腹有明显压痛,反跳痛及肌紧张,肝脾触诊不满意,移动性浊音阴性。临床诊断:梗阻性黄疽。
Patient, male, 36 years old. Due to no obvious incentive 2 years ago, the right upper quadrant pain, but soon to ease, the incidence of 7 days ago, consciously right upper quadrant pain worsened, with scleral yellowing, urinary pus-like, 3 days Potato stool was like, low-grade fever, the anti-infective treatment ineffective, to a clear diagnosis to our hospital. Physical examination: body temperature 37.8 degrees, blood pressure 12 / 6KPa, the general situation is acceptable, clear, acute pain, systemic skin and scleral yellow dye, abdominal full, right abdomen obvious tenderness, rebound tenderness and muscle tension, Not satisfied with the palpation of liver and spleen, mobility dullness negative. Clinical diagnosis: obstructive jaundice.