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患者,男,16岁,主诉发热、右上腹部疼痛4天,于1998年4月7日入院.4天前因淋雨后开始发热,体温38.5℃左右,伴右上腹部痛,纳差,在本校医务室诊断为上呼吸道感染,给予感冒通等药口服治疗,发热不退,右上腹部仍感疼痛,呕吐1次.既往身体健康.体检:体温39.6℃,脉搏104次/分,呼吸20次/分,血压17/11kPa.神志清,皮膜粘膜无黄染及出血点,浅表淋巴结无肿大,颈软,心肺无异常发现,右上腹部压痛明显,无肌紧张及反跳痛,肝胆未触及,肝区、右肾区有叩击痛,病理反射未引出.实验室检查:血常规:血红蛋白120g/L,白细胞9.7×10~9/L,中性0.67,淋巴0.33;血沉40mm/小时:肝功能正常;胸透未见异常;B超示胆囊炎.
Patient, male, 16 years old, complained of fever, right upper quadrant pain for 4 days and admitted to hospital on April 7, 1998. 4 days ago, the patient started to have fever after the onset of the rain with a body temperature of about 38.5 ° C, with right upper quadrant pain and anorexia at this school Medical office diagnosed as upper respiratory tract infection, given cold and other drugs oral treatment, fever, upper right abdomen still feel pain, vomiting 1. Previous physical examination: body temperature 39.6 ℃, pulse 104 beats / min, breathing 20 times / Points, blood pressure 17 / 11kPa. God clear, mucosa without yellow dye and bleeding point, superficial lymph nodes without swelling, soft neck, no abnormal heart and lung, upper right abdomen tenderness, no muscle tension and rebound tenderness, hepatobiliary not touched , Liver, right kidney area percussion pain, pathological reflex did not lead to laboratory tests: blood: hemoglobin 120g / L, white blood cells 9.7 × 10 ~ 9 / L, neutral 0.67, lymphatic 0.33; erythrocyte sedimentation rate 40mm / Liver function is normal; no abnormal chest X-ray; B ultrasound showed cholecystitis.