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病历摘要邹××,男,34岁,工人,住院号299721。因头晕、乏力、面色苍白2年于1982年4月24日入院。 1980年5月起渐觉头晕、乏力、颜面苍白。在某院查血红蛋白7.4克%,肌注维生素B_(12)、口服叶酸2月,症状无好转。后来间断服铁剂,常常是服半个月、停两个月,效果也不好。近半年来头晕加重,并感心悸。两天来解成形黑便3次。门诊以“贫血”收入院检查。病程中无发热以及牙龈、皮肤出血,未服阿司匹林类药物。无肺结核、肝炎、肾炎病史。1976年开始上腹饥俄样疼痛伴暖气、反酸、反复黑便,诊断为“十二指肠球部溃疡”而于1979年3月行胃大部切除、胃空肠吻合术。术前血红蛋白11克%,术后常吐苦水,饮食量少。体检:体温36.8℃,脉搏80次/分,呼吸20次/分,血压110/60毫米汞柱。发育正常,营养较差,皮肤及粘膜明
Medical record Summary Zou XX, male, 34 years old, worker, hospital number 299721. Due to dizziness, fatigue, pale 2 years in April 24, 1982 admission. May 1980 gradually dizzy, weakness, pale face. In a hospital check hemoglobin 7.4 g%, intramuscular injection of vitamin B_ (12), oral folic acid in February, no improvement in symptoms. Later, intermittent serving of iron, often serving half a month, stop two months, the effect is not good. Dizziness increased in the past six months, and feeling palpitations. Two days to shape the black three times. Clinic to “anemia” income hospital inspection. No fever during the course of disease and gums, skin bleeding, not taking aspirin drugs. No tuberculosis, hepatitis, nephritis history. In 1976 began appetite hunger-like pain with heating, acid reflux, repeated meconium, diagnosed as “duodenal ulcer” and in March 1979 underwent partial gastrectomy, gastrojejunostomy. Preoperative hemoglobin 11%, often vomiting bitter water, less food intake. Physical examination: body temperature 36.8 ℃, pulse 80 beats / min, breathing 20 beats / min, blood pressure 110/60 mm Hg. Normal development, poor nutrition, skin and mucous membrane