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病历报告刘××,男性,16岁,住院号1064795 病史:两个月来腿痛,以右腿明显。于12天前曾因发烧、浮肿、肝功损售以肝炎住入传染科。经庇肝及中药治疗三天,病情好转自动退院。近10天来症状加重,黄疸加深,伴恶心,呕吐、鼻衄、头晕,再次住入传染科。尿深黄,大便稀,呈褐色。4岁患小儿麻痹。体格检查:急性病容、神志恍惚,但能回答问话,计算力定向力正常,贫血外貌,巩膜及皮肤明显黄染,全身浮肿,无出血点及蜘蛛痣,两侧颈部
Medical records Liu × ×, male, 16 years old, hospital number 1064795 History: leg pain in two months to obvious right leg. In 12 days ago due to fever, edema, liver damage sale of hepatitis living in Infectious Diseases. Liver and Chinese medicine by three days of treatment, the condition improved automatically retreat. The symptoms have worsened in recent 10 days, jaundice deepened, with nausea, vomiting, epistaxis, dizziness, re-admitted to the Department of Infectious Diseases. Dark yellow urine, stools thin, brown. 4-year-old suffering from polio. Physical examination: acute disease, trance, but can answer the question, calculate the power of normal force, anemia appearance, sclera and skin clear yellow dye, body edema, no bleeding spots and spider nevus, both sides of the neck