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病历摘要患儿女,1 4/12岁,因纳差、皮肤黄染50天。于1984年1月3日入院。入院前两个月因发热、咳嗽,以肺炎曾住我院,住院一周后发现皮肤轻度黄染,查黄疸指数25单位,凡登白试验直接、间接反应均阳性,麝香草酚浊度试验2单位,硫酸锌浊度2单位,谷丙转氨酶314单位(正常116单位),共住院两周,肺炎治愈,但黄染未消而出院。出院后一直纳差、乏力,时有呕吐,大便色白,小便呈深黄色,消瘦,皮肤黄染加深,继用保肝药等无效而再度入院。未问出肝炎接触史。体格检查:体温36℃,脉搏116次/分,呼吸24次/分。神志清。皮肤巩膜轻度黄染,耳、鼻、口、心及肺未见异常。腹胀、软。肝上界在右第6肋间,下界肋下3厘米、剑突下2厘米,中等硬度,无触痛。
Medical records with children, 1 4/12 years old, due to anorexia, skin yellow dye 50 days. On January 3, 1984 admission. Two months before admission due to fever, cough, had pneumonia in our hospital, hospitalized a week later found the skin mild yellow dye, check the jaundice index 25 units, where Deng Deng white test direct and indirect reactions were positive, thymol turbidity test 2 units, 2 units of zinc sulfate turbidity, 314 units of alanine aminotransferase (normal 116 units) were hospitalized for two weeks, pneumonia cured, but yellow dye was not eliminated and discharged. Discharge has been anorexia, fatigue, sometimes vomiting, stool white, dark yellow urine, weight loss, dark yellow skin deepened, following the use of drugs such as liver and re-admitted to hospital again. Did not ask the history of hepatitis exposure. Physical examination: body temperature 36 ℃, pulse 116 beats / min, breathing 24 beats / min. Consciousness. Skin scleral mild yellow dye, ears, nose, mouth, heart and lungs no abnormalities. Bloating, soft. Liver upper bound in the right 6th intercostal space, the lower limit of the ribs 3 cm, 2 cm below the xiphoid, moderate hardness, no tenderness.