Detailed Treatment Process
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A 27-year-old man presented on June 20 with nausea, aversion to greasy food, poor appetite for more than a week, accompanied by yellow urine and epigastric pain. There was no fever. Outpatient laboratory tests showed total bilirubin 255.8 μmol/L. He was admitted the same day or the next (June 21). The following is the discharge summary. Admission date June 20 Discharge date July 28 Length of stay 38 days Main symptoms and signs on admission Admitted with “yellow urine and nausea for over two weeks.” Physical examination: Temperature 36.6°C, clear consciousness, normal mental status, severe jaundice of the skin, no obvious liver palms or spider nevi, severe jaundice of the sclerae, supple neck without resistance. Liver and spleen not palpably enlarged. No sternal tenderness. Symmetric tactile fremitus bilaterally, resonant percussion, coarse breath sounds in both lungs without dry or moist rales. Heart rate 73 beats/min, regular rhythm, no pathological murmurs. Soft abdomen without visible peristalsis or intestinal patterns, no tenderness. No palpable masses. Upper liver border at the 5th intercostal space in the right midclavicular line. Liver and spleen not palpable below the costal margin. Murphy sign negative. No shifting dullness. No renal angle tenderness. Bowel sounds 4 times/min. No abnormalities of the anus or external genitalia. No spinal deformity. No redness, swelling, or pain in the limb joints. No lower limb edema. Main laboratory results Urinalysis (06/21): Bilirubin 3+. Stool routine negative. Blood routine (06/21): White blood cells 7.8×10⁹/L, red blood cells 3.58×10¹²/L, hemoglobin 115.0 g/L, platelets 166×10⁹/L, neutrophils 54.5%. Biochemistry (06/21): ALT 88 U/L↑, AST 123 U/L↑, AST isoenzyme 30 U/L↑, total bilirubin 255.8 μmol/L↑, albumin 21.3 g/L↓, glucose 1.76 mmol/L, urea 2.6 mmol/L, creatinine 57 μmol/L, cystatin C 0.85 mg/L, potassium 3.6 mmol/L, sodium 138 mmol/L, chloride 113 mmol/L, uric acid 105 μmol/L↑, total cholesterol 2.03 mmol/L↑, triglycerides 1.61 mmol/L↑, creatine kinase 65.00 U/L, LDH 254 U/L↑, C-reactive protein 17 mg/L↑, procalcitonin 0.60 ng/ml↑, adenosine deaminase 30.9 U/L↑, amylase 55.6 U/L. Biochemistry (06/23): Free T4 15.48 pmol/L, free T3 2.39 pmol/L↑, T4 4.5 μg/dl↓, T3 1.61 ng/ml, TSH 3.20 μIU/mL, anti-TPO 46.58 IU/ml↑, anti-TG 103.21 IU/ml↑. Biochemistry (06/23): Hyaluronic acid 571.36↑, type III procollagen N-terminal peptide 16.71↑, laminin 1090.94↑; Biochemistry (06/23): PIVKA-II 1.3, AFP 9.22%, AFP heteroplasmon 32.28 ng/ml, AFP 61.82 ng/ml↑, CEA 3.39 ng/ml, CA-125 23.93 U/ml, CA15-3 15.71 U/ml, CA19-9 22.450 U/ml↑, CA50 285.13 U/ml↑, CA72-4 414.220 U/ml↑; D-dimer 1.5 mg/L. HBV-DNA negative. IgE 115.71 U/ml. Syphilis and HIV antibodies negative. Blood routine (06/26): White blood cells 10.0×10⁹/L, red blood cells 3.63×10¹²/L, hemoglobin 116.0 g/L, platelets 163×10⁹/L, neutrophils 57.8%. Biochemistry (06/26): ALT 84 U/L↑, AST 136 U/L↑, AST isoenzyme 33 U/L↑, total bilirubin 261.4 μmol/L↑, total protein 53.2 g/L↓, albumin 20.3 g/L↓, ALP 290 U/L↑, GGT 74 U/L↑, glucose 3.90 mmol/L, urea 3.0 mmol/L, creatinine 59 μmol/L, potassium 3.8 mmol/L, sodium 138 mmol/L, total cholesterol 2.17 mmol/L↓, triglycerides 1.70 mmol/L, LDH 278 U/L↑, C-reactive protein 8 mg/L. Immunology (06/26): HAV antibody negative, HBsAg 351.85 ng/ml↑, HBsAb 0.00 mIU/ml, HBeAg 11.656 PEIU/ml↑, HBeAb 0.00 PEIU/ml, HBcAb 3.17 PEIU/ml↑, HBcAb IgM 6.78 PEIU/L, HEV IgM negative, HCV antibody 0.37 (negative). Blood routine (07/05): White blood cells 10.0×10⁹/L, red blood cells 3.77×10¹²/L↑, hemoglobin 123.0 g/L, platelets 142×10⁹/L, neutrophils 51.6%. Biochemistry (07/05): ALT 69 U/L↑, AST 105 U/L↑, AST isoenzyme 240 U/L↑, total bilirubin 236.2 μmol/L↑, direct bilirubin 172.7 μmol/L↑, total protein 60.2 g/L, albumin 24.0 g/L↓, glucose 3.87 mmol/L, creatinine 60 μmol/L, potassium 4.1 mmol/L, sodium 138 mmol/L, chloride 106 mmol/L, urea 3.1 mmol/L, creatinine 2.73 mmol/L↑, triglycerides 1.67 mmol/L, creatine kinase 55.00 U/L, LDH 336 U/L↑, fucosidase 71.9 U/L↑, serum cholinesterase 2095.0 U/L↓, procalcitonin 1.23 ng/ml↑, adenosine deaminase 35.3 U/L↑, amylase 51.8↑. Biochemistry (07/07): Hyaluronic acid 650.01↑, type III procollagen N-terminal peptide 27.16↑, laminin 338.55↑, type IV collagen 1240.65↑. Biochemistry (07/07): Free T4 17.20 pmol/L, free T3 3.56 μIU/mL, anti-TPO 23.10 IU/ml, anti-TG 50.68 IU/ml. Prothrombin time 15.4 s. Blood routine (07/11): White blood cells 9.3×10⁹/L, red blood cells 3.52×10¹²/L↑, hemoglobin 118.0 g/L↓, platelets 130×10⁹/L, neutrophils 48.8%. Biochemistry (07/11): ALT 60 U/L↑, AST 91 U/L↑, AST isoenzyme 220 U/L↑, total bilirubin 148.2 μmol/L↑, total protein 53.8 g/L↓, albumin 21.1 g/L↓, ALP 347 U/L↑, GGT 52 U/L↑, glucose 3.98 mmol/L, urea 3.5 mmol/L, creatinine 60 μmol/L, potassium 3.9 mmol/L, sodium 138 mmol/L, chloride 106 mmol/L, total cholesterol 3.04 mmol/L↑, triglycerides 1.41 mmol/L↑, creatine kinase 45.00 U/L, LDH 297 U/L↑. Blood routine (07/26): White blood cells 10.4×10⁹/L↑, red blood cells 3.93×10¹²/L↑, hemoglobin 137.0 g/L, platelets 169×10⁹/L, neutrophils 34.1%. Biochemistry (07/26): C-reactive protein 5 mg/L. Biochemistry (07/26): ALT 51 U/L↑, AST 74 U/L↑, total bilirubin 103.3 μmol/L↑, total protein 67.5 g/L, albumin 26.0 g/L↓, glucose 3.93 mmol/L, urea 4.6 mmol/L, creatinine 65 μmol/L, cystatin C 1.01 mg/L, potassium 3.7 mmol/L, sodium 141 mmol/L, chloride 104 mmol/L, total cholesterol 51.20 mmol/L, creatine kinase 58.00 U/L, LDH 351 U/L↑, procalcitonin 0.32 ng/ml↑, amylase 52.2↑. Special investigations and important consultations Ultrasound (06/21): Liver parenchyma shows increased and coarse echogenicity; gallbladder wall edematous and thickened with enlarged gallbladder. Spleen, kidneys, ureters, bladder, and prostate show no obvious abnormalities. ECG (06/21): Normal sinus rhythm. Ultrasound (07/26): Liver parenchyma shows increased and coarse echogenicity; enlarged gallbladder with rough and thickened wall. Pancreatic body unremarkable. Spleen mildly enlarged. Course and treatment After admission, relevant examinations were completed. The patient received reduced glutathione, polyene phosphatidylcholine, hepatocyte growth-promoting factors, bitter yellow, and adenosylmethionine for liver protection, enzyme reduction, and jaundice relief. Alprostadil was given to improve systemic circulation. Amino acid infusion and human albumin were used to correct hypoalbuminemia. Cefmetazole was administered for anti-infection treatment. The patient requested discharge; after consultation with the attending physician, he was allowed to leave against medical advice with signed documentation. Complications: None Condition at discharge No nausea or vomiting. Abdominal distension and yellow urine had improved. Generalized fatigue and limb weakness persisted. No skin itching. Appetite fair without significant decrease. No clay-colored stools. No chest tightness or pain. Sleep satisfactory. Physical examination: Temperature 36.5°C, blood pressure 115/60 mmHg, clear consciousness, normal mental status, moderate jaundice of the skin, no obvious liver palms or spider nevi, smooth skin with good elasticity. Moderate jaundice of the sclerae. Supple neck without resistance. Trachea midline. Coarse breath sounds in both lungs without dry or moist rales. Heart rate 75 beats/min, regular rhythm, no pathological murmurs. Soft abdomen without visible peristalsis or intestinal patterns, no tenderness or palpable masses. Upper liver border at the 5th intercostal space in the right midclavicular line. Liver and spleen not palpable below the costal margin. Murphy sign negative. No shifting dullness. No renal angle tenderness. Bowel sounds 4 times/min. No lower limb edema. Post-discharge recommendations: Further treatment at a higher-level hospital. Rest adequately, take medications on time, and follow up regularly with liver function tests, HBV-DNA, ultrasound, AFP, etc. Medications dispensed: Ursodeoxycholic acid soft capsules 30# × 3 boxes, 2# tid po; Compound glycyrrhizin capsules 40# × 3 boxes, 2# tid po. Treatment outcome: Improved
The above is the content of the discharge summary. The day after discharge (July 29), the patient sought care at another hospital. Imaging (CT) at that facility showed local subcutaneous soft tissue edema in the gluteal-lumbar region (which had resolved) and no obvious abnormalities in the upper abdominal liver parenchyma. Given persistent jaundice and incomplete recovery of liver function, steroid therapy was administered (specific regimen unknown). Subsequent follow-up records show: Two years later (patient approximately 28–29 years old): Liver function had returned to normal, but imaging indicated diffuse liver disease. Four years later (patient approximately 30 years old): Liver function remained normal, but imaging showed diffuse liver disease with features approaching cirrhosis.