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患者吴淑德,女,65岁,住院号384。因阵发性上腹钝痛2年,加重6天入院。入院前返酸、嗳气、恶心、呕吐。痛放射右肩背,无心悸气促。发病以来,头晕失眠多梦、周身乏力。体检:T36.4℃,R20次/分,BP17/10kPa神萎,肥胖体型,二尖瓣面容,巩膜无黄染,面颈部毛细血管扩张,双肺呼吸音清,心率72次/分,律齐,无杂音。腹平坦软,肝脾未及,右上腹莫菲氏征阳性,余无异常发现。辅助检查:肝胆B超:胆轮廓欠清,边缘毛糙,约5×2.5cm,壁厚0.3cm,心电图:ST Ⅱ avF V_5略下移,血象:WBC5900/mm~3,N54％、L46％、Hb12.5g％,RBC420万/mm~3,尿检:
Patient Wu Shude, female, 65 years old, hospital number 384. Due to paroxysmal abdominal dull pain for 2 years, increased 6 days admission. Back to the hospital before the acid, belching, nausea, vomiting. Pain radiation right shoulder, no heart palpitations. Since the onset, dizziness, insomnia and more dreams, whole body fatigue. Physical examination: T36.4 ℃, R20 beats / min, BP17 / 10kPa atrophy, obese body, mitral surface, scleral no yellow dye, face and neck telangiectasia, lung breath sounds clear, heart rate 72 beats / min, Law Qi, no noise. Abdomen flat and soft, liver and spleen not yet, the right upper quadrant Murphy’s sign positive, I found no abnormalities. Auxiliary examination: Hepatobiliary B-ultrasonography: The outline of the gallbladder was not clear, the edge was rough, about 5 × 2.5cm, the wall thickness was 0.3cm. The electrocardiogram: ST Ⅱ avF V_5 slightly shifted downwards. The hemogram was WBC5900 / mm ~ 3, N54%, L46% Hb12.5g%, RBC4.2 million / mm ~ 3, urine test: