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患者,男,26岁,工人,于1994年6月2日入院。 主诉:发热4天,尿黄3天,腹痛1天。患者于入院前4天无明显诱因急性起病,高热(T39～40℃),伴头痛,少许清涕,咽不适感、乏力纳呆,恶心呕吐、腹胀。次日小便深黄如浓茶,巩膜、皮肤亦渐黄染。起病第二天门诊查血清总胆红素48.7mmol/L,GPT960u/L,血常规正常范围。第三天复诊时突然感左下腹疼痛,阵发加剧,伴寒战。约20分钟后自行缓解,但腹胀加重,此后体温渐趋正常。
Patient, male, 26 years old, worker, admitted to hospital on June 2, 1994. Chief complaint: fever for 4 days, urine yellow for 3 days, abdominal pain for 1 day. The patient had no obvious cause of acute onset 4 days before admission, high fever (T39 ~ 40 °C), headache, a little clear phlegm, pharynx discomfort, lack of fatigue, poor appetite, nausea and vomiting, abdominal distension. The next day urine dark yellow tea, the sclera, the skin is gradually yellow. On the second day of the onset of outpatient visits, serum total bilirubin was 48.7mmol/L, GPT 960u/L, and the normal range of blood was normal. On the third day of referral, she felt a sudden pain in the left lower abdomen, and her bursts increased, accompanied by chills. After about 20 minutes of self-relieving, but abdominal distension increased, then body temperature gradually normalized.