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患女,32岁,以乏力、纳差、尿黄20余天入院。乙型肝炎病史4年,入院前因劳累感全身乏力,恶心、呕吐、厌油,不能进食,尿黄为浓茶色。查体:T36.4℃,P78次/min,R20次/min,BP15/10kPa,慢性病容,皮肤及巩膜重度黄染,心、肺未见异常,腹稍隆起,肝、脾未及,全腹有压痛,腹水征阳性,双下肢水肿。实验室检查:GPT100U/L,TBIL-I391/μmol/L,DBILI134μmol/L,HBsAg(+),HBeAg(+),抗HBC(+),血清白蛋白29.2g/L,球蛋白24.8g/L,PT15s,腹水常规:比重1.020,WBC304/mm~3,N0.80,L0.20,血WBC1.2×10~9/L,N0.85,L0.15。诊断:慢
Women, 32 years old, with fatigue, anorexia, urinary yellow 20 days admission. Hepatitis B history of 4 years, due to fatigue before admission, fatigue, nausea, vomiting, tired of the oil, can not eat, urine yellow is dark brown. Examination: T36.4 ℃, P78 times / min, R20 times / min, BP15 / 10kPa, chronic disease, skin and sclera severe yellow dye, heart and lung no abnormalities, abdominal bulge, liver and spleen not all Abdominal tenderness, ascites sign positive, lower extremity edema. Laboratory tests: GPT100U / L, TBIL-I391 / μmol / L, DBILI134μmol / L, HBsAg (+), HBeAg (+), anti-HBC (+), serum albumin 29.2g / L, globulin 24.8g / L , PT15s, ascites routine: the proportion of 1.020, WBC304 / mm ~ 3, N0.80, L0.20, blood WBC1.2 × 10 ~ 9 / L, N0.85, L0.15. Diagnosis: slow