论文部分内容阅读
患者 赵×,男,30岁,业务员,病历号64325。因右上腹不适感2个月,突然右上腹疼1小时,来我院就诊。患者2个月来感到右上腹不适,似有逐渐加重趋势,无发烧及食欲不振,无恶心、呕吐及腹疼。入院1小时前,饭后活动中,突然出现右上腹疼,呈持续性、进行性加剧,并逐渐扩散至右侧腹。无呕吐、发烧。查体:体温36.7℃,脉搏90次/分,呼吸22次/分,血压16/11kPa,神清,急性痛苦病容,皮肤及粘膜未见异常,两肺无啰音,心界不大,腹部平、无肠
Patient Zhao X, male, 30 years old, salesperson, medical record number 64325. Due to discomfort in the right upper abdomen for 2 months, suddenly the right upper abdominal pain for 1 hour, to our hospital. The patient felt discomfort in the right upper quadrant for 2 months and it seemed to be gradually worsening. There was no fever and loss of appetite, no nausea, vomiting, and abdominal pain. One hour before admission, during the meal activity, there was a sudden abdominal pain in the right upper quadrant, which was persistent, progressively worsening, and gradually spread to the right abdomen. No vomiting, fever. Physical examination: body temperature 36.7°C, pulse 90 beats/minute, respiratory rate 22 breaths/minute, blood pressure 16/11 kPa, Shen Qing, acute pain, no abnormalities in skin and mucous membranes, no lung sounds in both lungs, no heart boundary, abdomen Flat, without intestine