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病历摘要【例1】许×,男,61岁,住院号99814,于1979年12月13日入院。主诉:上腹痛、寒战、发烧伴有黄疸两个月。近10天来腹痛加重,黄疸加深,体温时高时低,恶心、呕吐食物和苦水,大便浅黄色,尿呈浓茶色,食欲明显减退。一年前曾发作一次,当时无黄疽。查体:体温37.2℃,脉搏80次/分,血压140/90毫米汞柱,慢性病容,脉沉细,舌尖红、苔黄腻,皮肤、巩膜中度黄染,心肺未见异常,右上腹有轻度压痛,无反跳痛,莫菲氏征(一),肠音活跃,肝、脾、胆囊未触及。化验:血红蛋白12克%,白细胞总数11,000个/立方毫米,中性粒细胞84%。尿胆红质(+),尿胆原、尿胆素均为弱阳性。肝功:全蛋白6.3克%,白蛋白1.8克%,球蛋白4.5克%,胆红质8.73毫克%。黄疸指数90单位,GPT
Medical records [Example 1] Xu ×, male, 61 years old, hospital number 99814, was admitted on December 13, 1979. Chief complaint: upper abdominal pain, chills, fever with jaundice two months. The past 10 days to aggravate abdominal pain, jaundice deepening, high and low body temperature, nausea, vomiting food and bitter water, light yellow stool, urine was dark brown, loss of appetite significantly. A seizure occurred a year ago, when there was no jaundice. Physical examination: Body temperature 37.2 ℃, pulse 80 beats / min, blood pressure 140/90 mm Hg, chronic disease, pulse Shen, tongue red, yellow greasy fur, sclera moderate yellow dye, no abnormal heart and lung, right upper quadrant Have mild tenderness, no rebound pain, Murphy’s sign (a), active bowel sounds, liver, spleen, gallbladder not touched. Assay: hemoglobin 12 g%, total leukocytes 11,000 / mm3, neutrophils 84%. Urine bilirubin (+), urinary gallbladder, urobilinogen are weakly positive. Liver function: whole protein 6.3 grams, 1.8 grams of albumin, 4.5 grams of globulin, 8.73 mg of bilirubin. Jaundice index 90 units, GPT