论文部分内容阅读
男,干部,35岁,因大便次数增多于1979年10月来诊。诉近半年来每日大便4～5次,软或稀便,无里急后重,腹偶阵痛,便后即消,半年来体重减轻2.5kg,食量基本同前,性情尚好,无明显急躁、怕热多汗、心悸、乏力,既往无慢性腹泻及慢性咳嗽、潮热等病史。体查:神清,颈软,甲状腺不大,血压130/70,无突眼。双肺呼吸音清晰,心界不大,律齐,心率84次,未闻病理性杂音。腹平软,无压痛,未扪及包块,肠鸣音略亢进。双手平举无细震颤,四肚、脊柱均朱见异常。胸透:心肺正常。大便常规检查:黄色软便,高倍镜检见白细胞0～2,有未消化食物残渣。大便找抗酸菌三次均阴性。拟诊:慢性肠炎,腹泻原因待查。予以黄连素、复合维生素B等内服1周,症状如旧。随行乙状结肠镜检查,见乙状结肠粘膜充血,略粗糙,余未发现异常。乃以2％磺胺噻唑液200ml保留灌肠,每日1次,7天后疗效不佳。作胃肠X线钡餐检查,吞钡后1小时,钡剂即已
Male, cadre, 35 years old, due to an increase in stool frequency in 1979 October to the clinic. V. 4 to 5 times a day for nearly six months stool, soft or loose stools, no tenesmus, abdominal pain even after the abolition of the consumer, half a year to lose weight 2.5kg, basic food intake with the former, the situation is still good, no irritable, Hyperhidrosis, palpitations, fatigue, no previous chronic diarrhea and chronic cough, hot flashes and other medical history. Physical examination: God clear, soft neck, small thyroid, blood pressure 130/70, no exophthalmos. Breath sounds clear lungs, heart is not big, law Qi, heart rate 84 times, no pathological murmur heard. Abdomen soft, no tenderness, no palpable mass, bowel sounds slightly hyperthyroidism. No fine tremor hands flat, four belly, spine Zhu see unusual. Chest throat: normal heart and lungs. Stool routine examination: yellow loose stools, high power microscopy see leukocytes 0 ~ 2, there are undigested food residue. Stool to find acid-fast three times were negative. To be diagnosed: chronic enteritis, causes of diarrhea pending investigation. To be berberine, vitamin B and other oral 1 week, symptoms such as the old. Accompanied sigmoidoscopy, see congestion of sigmoid mucosa, slightly rough, I found no abnormalities. Is 2% sulfadiazine solution 200ml retention enema, 1 day, 7 days after the poor efficacy. Gastrointestinal X-ray barium meal examination, 1 hour after swallowing barium, that is, barium