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患者男,26岁,以右上腹隐痛一月余,伴腹胀,乏力为主诉。患者一月前无明显诱因,自觉右上腹痛,为持续隐痛,疼痛不向其他部位放射,伴腹胀,乏力,皮肤巩膜黄染,夜间腹泻,大便呈稀糊状,双下肢水肿,活动后双下肢水肿加重,休息后缓解,当以“肾炎、胆囊炎”予以抗感染治疗后,患者自觉好转,但腹痛、腹胀,皮肤巩膜黄染不缓解。体检:皮肤巩膜黄染,右上腹压痛,肝区叩击痛 (+),胃鼓音区向左移位,腹部移动性浊音
Male patient, 26 years old, to the right upper quadrant pain more than a month, with abdominal distension, fatigue-based complaints. Patients with no obvious incentive a month ago, conscious right upper quadrant pain, continuous pain, pain does not radiate to other parts, with abdominal distension, weakness, scleral skin yellowing, night diarrhea, stool was thin paste, double lower extremity edema, Edema aggravated rest after remission, when “nephritis, cholecystitis” to be anti-infective treatment, the patient improved, but abdominal pain, abdominal distension, skin scleral yellow dye does not ease. Physical examination: skin sclera yellow dye, tenderness in the right upper quadrant, percussion pain in the liver area (+), shift to the left of the gastric drum area, dull dullness of the abdomen