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1 病历摘要 男,27岁。患者巩膜、皮肤黄染,小便深黄1月余,伴发热、上腹部疼痛、腹胀、腹水,下肢浮肿1周入院。腹痛以蜷曲身体可缓解,进食后加重。胃纳可,无明显恶心呕吐,稍感乏力。起病以来,自服草药无效,黄疸进行性加深。查体:神清,巩膜、皮肤深黄,心肺(一),腹稍膨,剑下压痛(+),腹水征(+),肝触诊不满意,下肢浮肿。1994年1月15日B超示:慢性肝病,脾略大,中等量腹水,胆囊增大,壁略厚,胰头部实质性团块,肿瘤首先考虑(对胰腺多轴扫描,胰头至胰颈部探及—稍强回声团块,形态不规则似“菜花”状,表面可见数个“驼峰”
1 medical record summary male, 27 years old. Patient sclera, skin yellow dye, deep yellow urine 1 month, with fever, upper abdominal pain, bloating, ascites, lower extremity edema 1 week admission. Abdominal pain to curl the body can be alleviated, increased after eating. Noble appetite, no obvious nausea and vomiting, a little tired. Since the onset, self-serving herbs invalid, progressive jaundice deepened. Physical examination: Shen Qing, sclera, dark yellow skin, heart and lung (a), a slight swelling of the abdomen, tenderness under the sword (+), signs of ascites (+), liver palpation is not satisfied, lower extremity edema. January 15, 1994 B ultrasound showed: chronic liver disease, spleen slightly large, moderate amount of ascites, gallbladder increased, slightly thick wall, pancreatic head substantive mass, the tumor first consider (multi-axial pancreas, pancreatic head to Pancreas neck exploration and - slightly stronger echo mass, irregular shape like “Cauliflower” shape, the surface can be seen several “hump”