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病历摘要患者,男,15岁。因肝区痛,腹胀两月余,肝区痛加剧半天,于1977年12月5日入院。病后纳差,水泻一天2～3次,无发热。1977年10月2日因自觉肝痛腹胀半个月在本院门诊首次检查,发现腹部有移动性浊音,肝脾未触及。肝功:TTT5u,ZTT10u,GPT325u,蛋白正常,硷性磷酸酶11.4金氏单位,胎甲球(-)。超声波检查:肝上界5肋间,剑突下4cm,肋下(-),肝波迟钝微波,脾肋下(-)。诊断为:肝硬化、腹水,肝癌待除外。经门诊多次服用护肝药及利尿剂后病情仍继续加重。过去体健,未服用特殊药物。
Patient summary, male, 15 years old. Due to liver pain, bloating more than two months, liver pain intensified for half a day, on December 5, 1977 admission. Anorexia, watery diarrhea 2 to 3 times a day, no fever. October 2, 1977 due to liver pain and abdominal distension for half a month in our hospital for the first time examination and found that the abdomen with dullness, liver and spleen not touched. Liver function: TTT5u, ZTT10u, GPT325u, normal protein, alkaline phosphatase 11.4 Gold unit, fetal ball (-). Ultrasonography: upper intercostal space 5 intercostal, xiphoid 4cm, rib (-), microwave slow microwave, spleen ribs (-). Diagnosis: cirrhosis, ascites, liver cancer to be excluded. After repeated inpatients taking hepatoprotective drugs and diuretics, the condition continues to worsen. Past physical health, did not take special drugs.