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患者,男,35岁.因乏力、厌食、体重明显下降3个月,腹部胀痛20天收住院.16年前曾患“急性黄疸型肝炎”.查体:皮肤巩膜无黄染,未见蜘蛛痣及肝掌,浅表淋巴结未触及肿大.心肺(一).腹部膨隆,无腹壁静脉显露,腹肌轻度紧张,全腹压痛、反跳痛,肝脾触诊不满意,肝上界位于右锁骨中线第v肋间,肝叩击痛(+),漠氏征(+),腹水征(+),双下肢无水肿.肝功能:总胆红素及直接胆红素均正常,谷丙转氨酶正常,白蛋白42g/L,球蛋白35g/L,HBsAg
Patient, male, 35 years old. Due to fatigue, anorexia, body weight decreased significantly 3 months, abdominal pain 20 days admitted to hospital. 16 years ago had “acute jaundice hepatitis”. Physical examination: skin sclera no yellow, no Spider larvae and liver palms, superficial lymph nodes without swelling. Cardiopulmonary (a). Abdominal bulging, no abdominal vein exposure, mild abdominal muscle tension, abdominal tenderness, rebound tenderness, liver and spleen are not satisfied with palpation, liver The boundary is located in the intercostal space of the right clavicular line, liver pain (+), Mongolian sign (+), ascites sign (+), no lower extremity edema, liver function: total bilirubin and direct bilirubin are normal Normal alanine aminotransferase, albumin 42 g/L, globulin 35 g/L, HBsAg