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患者,男,29岁。因乏力,纳差,厌油,尿黄7d,于1994年3月13日入院。体检:体温36.7℃,脉搏76/min,呼吸18/min,BP16/10kPa发育正常,营养中等,皮肤轻度黄染,无出血点瘀斑蜘蛛痣皮疹和肝掌,浅表淋巴结不肿大,头颅五官正常,巩膜中度黄染,颈软,气管居中,甲状腺不肿大,心肺(一),腹平软,肝上界在右锁骨中线第五肋问,下界于右锁骨中线肋缘下1.5cm触及,质地中等硬度,有触痛,肝区有叩击痛,脾脏于肋缘下未触及,腹水征阴性,肠鸣音活跃,余无特殊。
Patient, male, 29 years old. Due to fatigue, anorexia, tired of oil, urine yellow 7d, on March 13, 1994 admitted. Physical examination: body temperature 36.7 ℃, pulse 76 / min, breathing 18 / min, BP16 / 10kPa normal development, moderate nutrition, skin mild yellow dye, no bleeding spots ecchymosis eczema and liver palms, superficial lymph nodes, Head normal facial features, sclera moderate yellow dye, neck soft, tracheal center, thyroid enlargement, cardiopulmonary (a), abdominal soft, upper liver in the right subclavian midline fifth rib asked, lower bound in the right subcostal midline rib margin 1.5cm touch, the texture of medium hardness, tenderness, liver percussion pain, the spleen in the marginal ribs did not touch, ascites sign negative, bowel sounds active, I no special.