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病历摘要:患者女,49岁,住院号50281。一年来大便不成形,消化不良。半年来主觉剑突下闷胀不适并有钝疼,牵及后腰背部。时轻时重,与饮食无关。发黄近一个月并有二次陶土便。未经治疗逐渐消退。既往有结核、肝炎接触史。检查:巩膜黄染,心肺无异常。剑突下扪之饱满感似囊性肿物,深压痛,腹软无肌紧张。右上腹深部扪及结节状肿块轮廓不清。肝脾(-),体表淋巴结不大,无色素沉着。胸透肺门钙化点。便匿血(-),血沉68毫米/小时,血常规正常,碱性磷酸酶50单位,肿瘤生化(+),血淀粉酶128单位(温氏法),血糖235毫克％,尿糖(±),甲胎蛋白(-),GPT194单位,TTT10单位,胆固醇250毫克％。钡透视:胃小弯呈弧形外压性改变,肝扫描,肝内未见占位性病变。“B”型超声(第一次)胆囊增大,胆总管扩张1.6厘米,肝内胆管扩张,胰腺增大轮
Medical record summary: patient female, 49 years old, hospital number 50281. Stool form a year, indigestion. Six months under the soxial kyphosis feeling uncomfortable and have a dull pain, involving lower back. When light weight, has nothing to do with diet. Yellow nearly a month and there are two clay. Without treatment gradually faded. Past history of tuberculosis, hepatitis exposure. Check: scleral yellow dye, no abnormal heart and lungs. Xiashu full palpable cystic mass, deep tenderness, abdominal soft muscle no muscle tension. Deep palpable right upper quadrant palpable mass outline unclear. Liver and spleen (-), body surface lymph node is not large, no pigmentation. Thoracic and calcification of the lung. (+), Blood amylase 128 units (Wen’s method), blood glucose 235 mg%, urine (±), blood sediment 68 mm / h, normal blood, alkaline phosphatase 50 units, ), Alpha-fetoprotein (-), GPT194 units, TTT10 units, cholesterol 250 mg%. Barium perspective: gastric curvature was curved external pressure changes, liver scan, no intrahepatic lesions. “B” type ultrasound (first) gallbladder enlargement, dilatation of the common bile duct 1.6 cm, intrahepatic bile duct dilatation, enlargement of the pancreas