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刘××,女性,27岁,住院号:88540。主因皮肤搔痒及尿黄半个月,巩膜黄染三天于1981年10月9日以急性黄疸型肝炎入我院传染科。患者半个月前无明显诱因出现全身皮肤搔痒及尿色深黄,近三天巩膜黄染,但精神好,食欲佳,无恶心、呕吐、厌油、腹疼、腹胀、发热及乏力等现象。既往史:健康,无肝胆系统疾患。月经史:18 (5～6)/(28～30),经量中等,痛经(-),末次月经为1981年5月8日,目前为首次妊娠5个月。家族史:无特殊记载。检查:体温37℃,脉搏88次/分,呼吸20次/分,血压100/70毫米汞柱。发育正常,皮肤轻度发黄,巩膜明显黄染,心肺正常,肝浊音界于
Liu × ×, female, 27 years old, hospital number: 88540. Mainly due to skin itching and urine yellow for half a month, scleral yellow dye three days in October 9, 1981 with acute jaundice hepatitis into our hospital Department of Infectious Diseases. Patients with no obvious incentive to appear half a month ago, body skin itching and dark yellow urine, scleral yellow dye nearly three days, but good spirit, good appetite, no nausea, vomiting, tired of oil, abdominal pain, bloating, fever and fatigue and so on . Past history: healthy, no hepatobiliary disease. Menstrual history: 18 (5 ~ 6) / (28 ~ 30), moderate volume, dysmenorrhea (-), the last menstrual period May 8, 1981, is currently the first pregnancy of 5 months. Family history: No special records. Check: body temperature 37 ℃, pulse 88 beats / min, breathing 20 beats / min, blood pressure 100/70 mm Hg. Normal development, mild yellow skin, sclera significantly yellow dye, normal heart and lung, liver dullness in the community