1 病历摘要患者,女,64岁,于入院一年前在进食油腻食物后,即出现上腹部不适,近一个月出现上腹部针刺样疼痛,向右肩背部放射。查体:T36.2℃,P80次/分,R20次/分,BP14.0/10.0kPa,全身皮肤、粘膜轻度黄染,浅表淋巴结无肿大,右上腹压痛,无反跳痛,Murphy’s征(一)肝脾肾均未触及,叩诊呈鼓音,移动性浊音(一),肠鸣音正常。 1 Medical record summary The patient, female, 64 years old, had a discomfort in her upper abdomen after eating oily food a year ago. In the past month, she experienced acupuncture-like pain in the abdomen and radiated to the right shoulder and back. Physical examination: T36.2°C, P80 beats/min, R20 beats/min, BP14.0/10.0kPa, slight yellowing of the skin and mucous membranes of the body, no swelling of superficial lymph nodes, tenderness of the right upper quadrant, no rebound tenderness, Murphy’s sign (a) liver, spleen and kidney were not touched, percussion was drum sound, mobile dullness (1), normal bowel sounds.