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患者男,50岁。因右上腹胀痛,纳差伴发热1月余入院。且乏力,恶心,厌油,体重减轻。大便1次/日,糊状。夜间发热,体温37.5℃～38.5℃。轻咳,少痰。曾抗炎对症治疗,症状减轻。无尿频、尿急、尿痛。夜尿多(日间2～3次,夜间4～5次)。查体:T37.5℃,P80次/分,BP14.7/9.3kPa。慢性病容,全身浅表淋巴结无肿大。巩膜无黄染。心肺(一),腹平软,剑下及右上腹压痛,肝脾肋下触及边缘,双肾区无叩击痛。
Male patient, 50 years old. Due to pain in the right upper quadrant, anorexia with fever more than 1 month admission. And fatigue, nausea, tired of oil, weight loss. Stool 1 / day, paste. Night fever, body temperature 37.5 ℃ ~ 38.5 ℃. Light cough, less sputum. Anti-inflammatory symptomatic treatment, reduce the symptoms. Urinary frequency, urgency, dysuria. Nocturia and more (during the day 2 to 3 times, night 4 to 5 times). Physical examination: T37.5 ℃, P80 beats / min, BP14.7 / 9.3kPa. Chronic disease, systemic superficial lymph nodes without swelling. Sclera without yellow dye. Cardiopulmonary (a), abdominal soft, under the sword and right upper quadrant tenderness, liver and spleen ribs touch the edge of the kidney area without percussion pain.