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患者×××,男,33岁,工人,住院号332765。患者于45天前发现巩膜发黄,同时出现小便颜色加深,但无自觉不适,无发热、右上腹疼痛等症状。于1987年12月7日到当地医院诊治。拟诊为“急性胆囊炎,胆结石、阻塞性黄疸”收入病房。住院期间查总胆红素7.0mg/dl,一分钟胆红素4.7mg/dlAKP2.58金氏单位,AFP (一),HBsAg(一),肝功能正常,A/G=4.8/3.2,胆固醇126mg/dl。尿胆红素、尿胆素、尿胆原(一),白细胞7400,中性70％,B型超声检查示胆囊炎、胆囊多发性结石,胆总管不扩张。经抗感染、消炎利胆治疗20多天,黄疸仍进行性加深,总胆红素20mg/dl小便如浓茶,大便颜色正常,全身皮肤深度黄染,伴明显瘙痒,乏力,食欲不振。于1988年1月21日住入本院。
Patient × × ×, male, 33 years old, worker, hospital number 332765. The patient had a yellowish sclera 45 days earlier with darker urinal color but no symptoms of unwell, no fever, and right upper quadrant pain. December 7, 1987 to the local hospital for treatment. To be diagnosed as “acute cholecystitis, gallstones, obstructive jaundice” income ward. During hospitalization, total bilirubin 7.0 mg / dl, one minute bilirubin 4.7 mg / dlAKP 2.58 gold units, AFP (one), HBsAg (one), normal liver function, A / G = 4.8 / 3.2, cholesterol 126mg / dl. Urinary bilirubin, urobilinogen, urobilinogen (a), 7400 white blood cells, neutral 70%, B-mode ultrasound showed cholecystitis, gallbladder multiple stones, common bile duct does not dilate. Anti-infective, anti-inflammatory treatment of gallbladder for more than 20 days, jaundice still progressive deepening, total bilirubin 20mg / dl urine such as strong tea, normal stool color, body skin depth yellow dye, with obvious itching, fatigue, loss of appetite. January 21, 1988 admitted to the hospital.