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病例资料患者,女,72岁。因反复右上腹疼痛3 d入院。患者入院前3 d无明显诱因出现右上腹疼痛,无返酸、嗳气,无腹胀、腹泻,无恶心、呕吐,无畏寒、发热。查体:体温36.5 C°,心率78次/min,血压120/90 mm Hg(1 mm Hg=0.133 kPa);腹平坦,腹软,剑突下及右上腹轻压痛,无反跳痛;右上腹触及肿大的胆囊,约6.0 cm×6.0 cm大,质地韧,Murphy征(+);肝脾肋缘下未触及;肠鸣音2～3次/min。血常规及肝功能正常;CA19-9、AFP及CEA在正常范围。
Case information patients, female, 72 years old. Due to repeated right upper quadrant pain 3 d admission. There was no obvious cause of right upper quadrant pain, no acid reflux, belching, no bloating, no diarrhea, no nausea, vomiting, no chills and fever in 3 days before admission. Examination: body temperature 36.5 C °, heart rate 78 beats / min, blood pressure 120/90 mm Hg (1 mm Hg = 0.133 kPa); abdominal flat, abdomen soft, under the xiphoid and right upper quadrant mild tenderness, no rebound pain; Abdominal touches the enlargement of the gallbladder, about 6.0 cm × 6.0 cm large, tough texture, Murphy sign (+); liver and spleen ribs were not touched; bowel sounds 2 to 3 times / min. Blood and liver function is normal; CA19-9, AFP and CEA in the normal range.