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患者陈某,男,40岁,工人。因上腹部隐痛一月余,呕吐咖啡样液体三次,解黑使二次,以“上消化道出血”于1984年12月9日入院。体检:T 38.1℃,R21次,P92次,BP13.33/8.2646KPa(100/60mmHg)。神清,清瘦,面色苍白,皮肤,巩膜未见出血点及黄染。心,肺正常。腹平软,上腹部正中有明显压痛,无反跳痛,肝脾未触及,无包块,肠鸣音稍亢进。其他检查皆正常。化验Hb86g/L(8.6g/dL);WBC5800,N 80,L36;尿常规,大便常规正常,大便潜血
Patient Chen, male, 40 years old, worker. Due to pain in the upper abdomen more than a month, vomiting coffee-like liquid three times, black to make the second, to “upper gastrointestinal bleeding” on December 9, 1984 admission. Physical examination: T 38.1 ℃, R21 times, P92 times, BP13.33 / 8.2646KPa (100 / 60mmHg). God clear, thin, pale, skin, sclera no bleeding point and yellow dye. Heart, lungs normal. Abdomen is soft, the middle of the abdomen there is obvious tenderness, no rebound pain, liver and spleen not touched, no mass, bowel sounds slightly hyperthyroidism. Other tests are normal. Laboratory Hb86g / L (8.6g / dL); WBC5800, N80, L36; urine routine, stool routine normal, fecal occult blood