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患者 男,44岁,因头昏、头痛、乏力、低热、尿黄、口苦、面部色素斑2月,于1997年1月20日入院.既往身体健康,否认肝炎、胃病及血液系统疾病史.体检:T37.8℃,睑结膜略苍白,巩膜中度黄染,面颊部大片蝴蝶斑样色素沉着,心肺正常,腹软,肝肋下1cm,质软,轻度压痛,脾不大,下肢轻度凹陷性水肿.实验检查:肝功能 TBIL35.3μmol/L,DBIL12.7μmol/L.ALT135U/L,AST68U/L,TB、A/G、蛋白电泳均正常.肝炎病毒血清标志物(ELISA法)抗HAV-IgM(一),抗HCV(一),HBsAg、抗HBe、抗HBc均阳性.血常规:Hb62g/L,WBC2.5×10~9/L,RBC3.2 ×10~(12)/L,BPC76×10~9/L,网织红计数0.5%,HCTO.32,MCV100fL,MCH1.20fmol,MCHC12.0mmol/L,入院诊断:①病毒性肝炎,急性黄疸型(乙肝);②贫血原因待查.
Male, 44 years old, admitted to hospital on January 20, 1997 due to dizziness, headache, weakness, fever, dark urine, mouth pain and facial pigmentation in January and was admitted to the hospital on January 20, 1997. In the past, he was in good health and deny the history of hepatitis, stomach and blood diseases Physical examination: T37.8 ℃, palpebral conjunctiva slightly pale, sclera moderate yellow dye, cheek large butterfly spot pigmentation, normal heart and lungs, abdominal soft, liver ribs 1cm, soft, mild tenderness, spleen not, Lower edema mild depression edema.Experimental examination: liver function TBIL35.3μmol / L, DBIL12.7μmol / L.ALT135U / L, AST68U / L, TB, A / G, protein electrophoresis were normal.Hepatitis virus serum markers Hb62g / L, WBC2.5 × 10 ~ 9 / L, RBC3.2 × 10 ~ (1), anti-HCV 12) / L, BPC76 × 10 ~ 9 / L, reticulocyte count 0.5%, HCTO.32, MCV100fL, MCH1.20fmol, MCHC12.0mmol / L, admission diagnosis: ①Viral hepatitis, acute jaundice (hepatitis B) ; ② cause of anemia to be investigated.