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病历摘要患儿男,6岁,因高热三周,黄疸两周于当年3月21日入院。患儿于入院前20天突然高热,食欲不振,恶心呕吐,7天后发现尿色如浓茶,双眼发黄且逐日加深。病后10天县医院以肝炎收入院治疗。经注射青霉素及保肝等治疗,体温39～40℃不降,黄疸加深,遂转来我院。既往无肝炎史,无肝炎病人接触史及输血史。入院时体温39℃,脉搏85次,血压14.7/10.7kPa(110/80mmHg),呼吸18次。意识清楚合作,营养尚好,皮肤巩膜中度黄染,无出血、皮疹,浅表淋巴结不大。双眼睑轻度浮肿,咽无充血,扁桃体不肿大。心肺如常,腹平软,肝于肋缘下1cm,边钝,质中,轻度压痛。脾肋缘下2cm,腹水征(-)。心电图示
Medical records Male children, aged 6, due to high fever for three weeks, jaundice two weeks on March 21 that year was admitted. Children in the hospital 20 days before suddenly high fever, loss of appetite, nausea and vomiting, urine color after 7 days such as strong tea, yellow eyes and deepening day by day. Ten days after the hospital county hospital for hepatitis treatment. After injection of penicillin and liver protection and other treatment, body temperature 39 ~ 40 ℃ do not drop, jaundice deepened, then transferred to our hospital. No past history of hepatitis, no history of hepatitis and history of blood transfusion. The body temperature at admission 39 ℃, pulse 85 times, blood pressure 14.7 / 10.7kPa (110 / 80mmHg), breathing 18 times. Clear awareness of cooperation, nutrition is still good, the skin sclera moderate yellow dye, no bleeding, rash, superficial lymph nodes is not large. Eyelid mild edema, pharyngeal no congestion, tonsil does not enlarge. Cardiopulmonary as usual, abdominal soft, liver in the rib margin 1cm, while blunt, quality, mild tenderness. Spleen under the edge of 2cm, ascites sign (-). ECG illustration