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病历摘要王××,男性,25岁,防疫站化验员,皖籍,住院号6032,入院日期1974年6月26日。主诉:发现巩膜皮肤黄染五年。现病史:患者于1969年上半年被别人发现有眼黄,当时食欲尚好、无自觉症状、小便色黄疑为“肝炎”,曾先后住院数次,肝功均正常,而黄疸指数偏高,住院期间曾作十二指肠引流及胆囊造影、结果不详,一直未明确诊断。 1971年又查肝功,其结果为黄疸指数20单位,凡登白呈双相反应,余均正常,AKP 12.1单位,尿三胆正常、BSP在45分钟为6.25％,HAA阴性,十二指肠引流正常,口服胆囊造影剂胆囊不显影;曾用中药及激素治疗均未见效。
Medical records Wang × ×, male, 25 years old, epidemic prevention station laboratory technician, Anhui Ji, hospital number 6032, admission date June 26, 1974. Chief complaint: scleral skin yellow dye found five years. Current history: The patient was found in the first half of 1969, there are eye yellow, was still good appetite, no symptoms, urine yellow suspected “hepatitis”, has been hospitalized several times, liver function are normal, and high jaundice index, During hospitalization for duodenal drainage and gallbladder angiography, the results unknown, has not been clearly diagnosed. 1971 and check liver function, the results for the jaundice index 20 units, where Deng white showed a biphasic response, the remaining normal, AKP 12.1 units, urinary gallbladder normal, BSP in 45 minutes to 6.25%, HAA negative, duodenal drainage Normal, oral gallbladder contrast medium gallbladder does not develop; have used traditional Chinese medicine and hormone therapy were not effective.