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1 病历摘要 1.1 患者:男性、17岁,两天前因劳累后饮啤酒一瓶,数小时后感上腹疼痛、恶心、频繁呕吐,后是有心悸、乏力。以急性胃炎介绍收住院。查体:体温37.8℃、脉搏110次/分、呼吸25次/分、血压13.5/11Kpa,意识清精神差,呈急性病容,胸廓无畸形,左胸下部叩呈鼓音,左肺下部呼吸音较对侧弱,右肺呼吸音清,心浊音界不满意,各瓣膜未闻及杂音,腹部软,左上腹区域扪痛,肝脾肋缘下未及,肠鸣音正常。 1.2 实验室检查:血常规:WBC14.5×10~9/L、RBC4.8×10~(12)/L、HB140g/L、L0.25、N0.75,X线检查报告:左侧隔肌明显抬高,胃泡明显扩大,胃内
1 Medical summary 1.1 Patients: male, 17 years old, two days ago due to fatigue after drinking a bottle of beer, a few hours after the upper abdominal pain, nausea, frequent vomiting, there is palpitations, fatigue. Introduced to hospital with acute gastritis. Physical examination: body temperature 37.8 ℃, pulse 110 beats / min, breathing 25 beats / min, blood pressure 13.5 / 11Kpa, consciousness of the spirit of poor, was acute disease, thoracic no deformity, left lower chest knocking was drum sound, lower left lung breath sounds Weak than the opposite side of the right lung breath sounds clear, voiced voice are not satisfied with the heart, the valve did not smell and noise, abdomen soft, pain in the left upper quadrant region, liver and spleen under the edge of the ribs, bowel sounds normal. 1.2 laboratory tests: blood: WBC14.5 × 10 ~ 9 / L, RBC4.8 × 10 ~ (12) / L, HB140g / L, L0.25, N0.75, X-ray examination report: left septal Muscle was significantly elevated, significantly enlarged stomach, stomach