论文部分内容阅读
男,20岁,农民。因酗酒后自觉上腹胀、腹泻、疲乏无力。体检:T38.5℃,P88次/min,R23次/min,BP16/9Kpa。热病容,营养中等,皮肤粘膜无出血点、皮疹及黄染,浅表淋巴结不大,心脏无异常,腹平软,剑突下轻压痛,肝肋下1 cm,脾肋下2 cm,质韧无压痛,腹水征可疑。腹部B超:肝肋下20mm,脾肋下54.7mm,肝左外叶上段有58×54.5mm低回声团块,后腹膜淋巴结肿大,腹盆腔少量积液。血:WBC 17.7×10~9/L,N0.92,L0.03,AFP<20μg/L,肝肾功能正常,ESR 107mm/h。初诊:肝脓肿。给予抗生素治疗,7d后体温正常,以肝内病灶
Male, 20 years old, farmer. Because of alcoholism consciously bloating, diarrhea, fatigue and weakness. Physical examination: T38.5 ℃, P88 times / min, R23 times / min, BP16 / 9Kpa. Fever, moderate nutrition, skin and mucous membrane without bleeding point, skin rash and yellow dye, superficial lymph nodes, heart no abnormalities, abdomen soft, xiphoid tenderness, hepatic ribs 1 cm, splenic ribs 2 cm, quality Tough without tenderness, signs of ascites suspicious. Abdominal B ultrasound: liver ribs 20mm, spleen ribs 54.7mm, the upper left hepatic lobe 58 × 54.5mm low echo mass, retroperitoneal lymph nodes, a small amount of pelvic fluid. Blood: WBC 17.7 × 10 ~ 9 / L, N0.92, L0.03, AFP <20μg / L, normal liver and kidney function, ESR 107mm / h. New diagnosis: liver abscess. Given antibiotics, 7d after normal body temperature to intrahepatic lesions