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患者(住院号68157)男,32岁,农民,于1980年4月28日住院.住院前40多天经常排柏油样便,自觉心慌、头晕、纳差、食后上腹胀满不适,偶而腹部隐痛,但无呕血、吐酸等症状.曾服消溃宁(以海螵蛸、元胡等为主要成份而制成的成药)、云南白药和驱虫药,柏油便随之改变为暗红色溏便;后又服健胃、止血、抗贫血等药无效.于4月28日以上消化道出血、胃溃疡(?)入我院.查体:重度贫血貌,皮肤未发现皮疹和紫癜,有下肢浮肿,全身浅淋巴结未触及,巩膜无黄染,两肺正常,心尖部可闻及Ⅲ级收缩期杂音,律齐,心率100次/分,心界不扩大,腹部及神经系统正常.实验室检查:血红蛋白38%,红细胞110万,白细胞15200,中性55%,淋巴17%,嗜酸细胞28%,红细胞压积24%,出凝血时间正常,红细胞平均血红蛋白25.5微微克,红细胞平均体积84.5立
Patient (hospital number 68157) Male, 32 years old, farmer, hospitalized on April 28, 1980. Often more than 40 days prior to hospitalization, they were aspirated, consciously flustered, dizzy, and poor appetite. Pain, but no hematemesis, spit acid and other symptoms. Served before the collapse of Ning (sea 螵 蛸, Yuan Hu, etc. as the main ingredient made of the drug), Yunnan Baiyao and deworming medicine, tar will be changed to dark red After April 28, more than gastrointestinal bleeding, gastric ulcer (?) Into our hospital. Physical examination: severe anemia appearance, the skin was not found rash and purpura, Lower extremity edema, systemic superficial lymph nodes not touched, scleral no yellow dye, both lungs normal, apex can be heard and Ⅲ systolic murmur, law Qi, heart rate 100 beats / min, the heart does not expand, the abdomen and nervous system normal. Laboratory tests: hemoglobin 38%, red blood cells 1.1 million, white blood cells 15200, 55% neutral, lymphatic 17%, eosinophils 28%, hematocrit 24%, the normal clotting time, average erythrocyte 25.5 pg, erythrocyte mean Volume 84.5 legislation