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1病历简介病人女性,81岁,因“间断性右上腹疼痛1周伴乏力”于2013-11-20入院。既往有冠心病和2型糖尿病病史。查体:全身皮肤及巩膜无黄染,腹软,右上腹压痛,无反跳痛,Murphy征可疑阳性,肝脾肋下未触及,移动性浊音阴性。肝功能提示:谷氨酸转氨酶47 U/L,白蛋白28 g/L,碱性磷酸酶736 U/L。血常规提示:白细胞10.5×109/L,中性粒细胞百分比为82.3%,血红蛋白77 g/L。超声示:胆囊结石并胆囊炎,胆囊窝积液,肝脏多发实质性病灶。MRI示:胆囊炎并多发结石,不排除胆囊肿瘤,肝脏多发小结节,腹腔积液。剖腹探查发现,胆囊与大网膜、胃等粘连紧密并侵犯相邻组织,胆囊与网膜及右肝相侵犯处组织破裂出血,另
A medical history Brief introduction Female patient, 81 years old, because of “intermittent right upper quadrant pain 1 week with fatigue” in 2013-11-20 admission. Past history of coronary heart disease and type 2 diabetes. Physical examination: body skin and sclera no yellow dye, soft belly, right upper quadrant tenderness, no rebound tenderness, Murphy sign suspicious positive, liver and spleen ribs untouched, shifting dullness negative. Liver function tips: glutamate aminotransferase 47 U / L, albumin 28 g / L, alkaline phosphatase 736 U / L. Blood routine tips: white blood cells 10.5 × 109 / L, the percentage of neutrophils was 82.3%, hemoglobin 77 g / L. Ultrasound showed: gallstones and cholecystitis, gallbladder fossa, liver multiple substantive lesions. MRI showed: cholecystitis and multiple stones, do not rule out gallbladder tumors, multiple nodules of the liver, ascites. Caesarean exploration found that the gallbladder and the omentum, stomach and other adhesions close and violations of adjacent tissues, gallbladder and omentum and the right liver invasion of tissue rupture bleeding, the other