论文部分内容阅读
病历摘要患者陈××,男性,36岁,某部工程师,已婚。主诉发热、上腹痛已十天,心慌、气短、呼吸困难五天而于1963年8月15日由某院转入我院。患者于8月4日晚餐饮酒后与爱人争吵,次日即感到心窝部不适。8月5日晚间突感中上腹部阵发性剧烈疼痛,不向他处放射,旋即噁心、呕吐,吐出食物残渣,不呈咖啡色,无腹泻,当即送往某医院,检查体温38.2℃,白细胞18,800,中性87%,淋巴13%。胸部透视右肺下部有模糊阴影,当时诊断为:1.急性胃炎;2.早期肺炎;经用硫酸阿托品注
Patient summary Chen × ×, male, 36 years old, an engineer, married. Chief complaint fever, upper abdominal pain has been ten days, palpitation, shortness of breath, difficulty breathing for five days in August 15, 1963 from a hospital into our hospital. The patient quarreled with his lover on the evening of August 4, and he felt discomfort in his heart the next day. On the evening of August 5, sudden and intermittent pain was found in the upper abdomen and no radiation was emitted to him. Immediately, nausea and vomiting were ejected. No residue of coffee and no diarrhea were immediately taken to a hospital for examination. The body temperature was 38.2 ° C and white blood cells 18,800, neutral 87%, lymph 13%. Chest fluoroscopy shadow of the lower part of the lower right, then diagnosed as: 1. Acute gastritis; 2. Early pneumonia; atropine sulfate injection