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1病历摘要男,44岁。主因腹痛伴乏力、纳差20 d于2010-01-02入院,患者曾因慢性胃炎、便秘、失眠口服中药(具体成分不详)40d余,腹部出现持续性隐痛,与体位无关,偶有胸骨后烧灼感,无腹泻、黑便及反酸烧心,入院体征:贫血貌、皮肤苍白,精神、睡眠差,纳差,腹部柔软,无腹部体征,大便2～3 d/次,为少量黑褐色成形便。检查胃镜无异常,肠镜示结肠息肉,內镜下夹除
1 medical record summary male, 44 years old. Mainly due to abdominal pain with fatigue, anorexia 20d admitted to the hospital on January 1, 2010, patients had chronic gastritis, constipation, insomnia oral traditional Chinese medicine (specific composition unknown) 40d more than persistent abdominal pain, nothing to do with the position, occasional sternal Burning, no diarrhea, melena and heartburn, admission signs: anemia appearance, pale skin, poor sleep, anorexia, abdominal soft, no abdominal signs, stool 2 ~ 3 d / time, a small amount of dark brown Will Check gastroscopy without exception, colonoscopy showed colon polyps, endoscopic clip