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1病历摘要患者男,19岁。因中上腹痛伴恶心、呕吐5小时于1998年8月16日入院。饥饿2天后感中上腹胀痛,呈持续性,偶尔加剧,不伴肩背放射痛,伴恶心,呕吐1次,呕吐物为胃液、胆汁等,解大便一次。查体:T37.4℃,P80次/分,R23/分,BP142/97mmHg。急性痛苦貌,心肺(—);腹平,未见肠型、胃型及蠕动波。腹软,剑突下偏右压痛,无反跳痛,肝脾未扪及,双肾区无叩痛,移浊(-),振水音(-)。肠鸣音不亢进。实验检查血常规:
1 medical record summary male patient, 19 years old. Because of abdominal pain with nausea, vomiting 5 hours in 1998 August 16 admission. Suffering from hunger 2 days after the upper abdominal pain, was persistent, and occasionally aggravating, without shoulder radiating pain, with nausea, vomiting 1, vomit for the gastric juice, bile, relieve stool time. Physical examination: T37.4 ℃, P80 beats / min, R23 / min, BP142 / 97mmHg. Acute pain appearance, heart and lung (-); abdominal flat, no intestinal type, gastric and peristaltic waves. Abdominal soft, xiphoid right tenderness, no rebound pain, liver and spleen not palpable, no percussion pain in the kidneys area, moving turbid (-), vibration sound (-). Bowel sounds are not hyperthyroidism. Experimental examination of blood: