急性胆囊炎病历书写范文
    英文回答：
    Acute Cholecystitis Medical Record.
    Patient Information:
    Name: [Patient's Name]
    Age: [Patient's Age]
    Gender: [Patient's Gender]
    Date of Admission: [Date of Admission]
    Date of Discharge: [Date of Discharge]
    Chief Complaint:
    The patient presented with severe right upper quadrant abdominal pain, radiating to the back, accompanied by nausea and vomiting.
    History of Present Illness:
    The patient experienced the onset of abdominal pain three days ago. The pain was initially mild but gradually worsened over time. The patient also reported loss of appetite and low-grade fever. The pain became excruciating and prompted the patient to seek medical attention.
    Past Medical History:
    The patient has a history of gallstones and has experienced intermittent episodes of biliary colic in the past.
    Physical Examination:
    On examination, the patient appeared in distress and had tenderness in the right upper q
uadrant of the abdomen. Murphy's sign was positive. Vital signs were within normal limits except for a slightly elevated body temperature.
    Laboratory Findings:
    Complete blood count showed leukocytosis with a left shift.
    Liver function tests revealed mildly elevated liver enzymes.
    Serum amylase and lipase levels were within normal limits.
uneventful
    Imaging Studies:
    Abdominal ultrasound demonstrated gallbladder wall thickening, pericholecystic fluid, and gallstones. No evidence of common bile duct dilation was noted.
    Diagnosis:
    Based on the clinical presentation, physical examination findings, laboratory results, and imaging studies, the patient was diagnosed with acute cholecystitis.

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