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病历摘要:患者沈××,14岁,女性,学生,住院号133427。以乏力、腹胀、全身发黄,近20天加重于1981年11月9日入院。“感冒”起病,乏力、纳减、胃胀两月余,近20天全身发痒,大便如陶土,小便如浓茶,周身发黄加重。无皮下及口鼻出血。院外按急性肝炎用中药和能量合剂加地塞米松治疗17天无效。入院体查:T36.8℃,P61次/分,BP90/60mmHg。神志清楚,查体合作,皮肤粘膜重度黄染,无出血,浅表淋巴结不肿大,心肺(-)。腹平软,肝上界第6肋,下沿肋下2cm,剑突下3cm,质中等,表面平,边缘钝,触痛(+),脾(-),
Medical record summary: The patient Shen × ×, 14 years old, female, student, hospital number 133427. To fatigue, bloating, yellow body, nearly 20 days aggravated in November 9, 1981 admission. “Cold” onset, fatigue, Minato, bloating more than two months, nearly 20 days whole body itching, stool, such as clay, urine such as strong tea, whole body yellowing worse. No skin and nose and mouth bleeding. Hospital by acute hepatitis with traditional Chinese medicine and energy mixture plus dexamethasone treatment for 17 days is invalid. Admission investigation: T36.8 ℃, P61 times / min, BP90 / 60mmHg. Consciousness, physical examination, severe skin and mucous membrane yellow dye, no bleeding, superficial lymph nodes are not enlarged, cardiopulmonary (-). Abdomen flat and soft, the upper rib 6th rib, along the ribs 2cm, xiphoid 3cm, medium quality, flat surface, blunt edge, tenderness (+), spleen