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病历摘要赵××,男,67岁,住院号213395,因吞咽困难,声音嘶哑二个月,牙龈出血一个月,头晕、黑便二周于1988年4月23日入院.患者于入院前二个月突然出现吞咽困难及声音嘶哑,尚能进干饭,无进行性加重.在当地医院给予口服药治疗(具体不详),病情无明显好转.于一个月前出现牙龈出血不止到口腔科就诊,给予拔牙及缝合止血,检查发现牙龈多处渗血,怀疑出凝血机制障碍转内科治疗。在内科门诊查出凝血时间及血小板均正常,故未予处理,入院前二周,出现柏油样便,每日1～2次,每次约200g,伴头晕及全身乏力,无呕血,伴低热.急诊纤维胃镜检查发现“球前壁潮红伴糜烂”,以“消化道出血原因待查”收住院.既往史:有“颈部包块”10年余,否认心、肝、肺、肾疾病,无药物过敏史。体检:T37.0℃,P92次/分,R22次/次,BP130/90mmHg,神志清楚,慢性病容,重度贫血貌,
Medical record summary Zhao X, male, 67 years old, hospital number 213395, dysphagia, hoarseness for two months, bleeding gums for one month, dizziness, black stools admitted to hospital on April 23, 1988, two weeks before admission. Months of sudden dysphagia and hoarseness, still able to enter the dry food, without progressively worsening. In the local hospital to give oral medication (specifically unknown), the condition was not significantly improved. A month ago, gum bleeding did not stop at the dentistry, Tooth extraction and suturing were used to stop the bleeding. The gum was found to be bleeding through multiple examinations, and it was suspected that the mechanism of clotting was transferred to medical treatment. The clotting time and platelets were normal in the internal medicine clinic, so they were not treated. Two weeks before admission, there was tarry stool, 1 or 2 times a day, each time about 200g, with dizziness and generalized fatigue, no vomiting, and low fever The emergency fiberoptic gastroscopy found that “the ball before the flush with erosion”, “indifferent causes of gastrointestinal bleeding” admitted to hospital. Past history: “neck mass” more than 10 years, denied heart, liver, lung, kidney disease No history of drug allergy. Physical examination: T37.0°C, P92 beats/min, R22 beats/time, BP130/90mmHg, conscious, chronic disease, severe anemia