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患者男,31岁,因左上腹胀闷不适一月,左上腹胀痛9天于1992年6月12日入院。1月前无明显诱因出现左上腹胀闷不适,不思饮食,服用“食母生”等药物,症状略好转,9天前症状加重,并伴左上腹疼痛。既往无肝炎、结核病史及血吸虫密切接触史,个人史、家族史无特殊。体检:体温36.2℃,脉搏80次/分,呼吸20次/分,血压16/12kPa,自动体位,意识清,慢性病容,全身皮肤粘膜无出血点及瘀斑,全身浅表淋巴结无肿大,胸廓无畸形,双肺(一),心率80次/分,律齐,未闻及病理杂音,左上腹膨隆,脾平脐触及,压痛、叩击痛(+),肝肋下未及,肠鸣音正常,脊柱生理曲度存,四肢肌力V
Patient Male, 31 years old, suffering from unpleasant upper left abdominal distention in January, left upper quadrant pain nine days on June 12, 1992 admitted. 1 month ago there was no obvious incentive to appear left upper quadrant distention and discomfort, do not think of diet, taking “food mother ” and other drugs, the symptoms slightly improved, 9 days ago, symptoms aggravated, accompanied by left upper quadrant pain. No past history of hepatitis, tuberculosis and schistosome close contact history, personal history, family history no special. Physical examination: body temperature 36.2 ℃, pulse 80 beats / min, breathing 20 beats / min, blood pressure 16 / 12kPa, automatic position, consciousness, chronic disease, systemic skin and mucous membrane without bleeding and ecchymosis, systemic superficial lymph nodes without swelling, Thoracic deformity, lungs (a), heart rate 80 beats / min, law Qi, no smell and pathological noise, left upper quadrant bulging, splenic touch of umbilical, tenderness, percussion pain Normal beep, spinal curvature, limb muscle strength V