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男,35岁,矿工。住院号208030。以腹泻、头昏、乏力10个月入院。10个月前饮食不洁后纳差、腹痛,腹泻每日2-8次,粘液糊状,服黄连素及中药一个月,纳差、头昏、乏力逐渐加重。近二个月吞咽梗阻、呕吐、脱肛,大便稀水样,褐色,全身衰竭,生活不能自理。查体:营养极度不良,体重36公斤,身高167厘米,精神萎靡,少气懒言,贫血貌,皮肤干燥,下肢浮肿,神经系统等无异常体征。Hb4.3g/mm~3,WBC1190/mm~3,PC8 000/mm~3,Ret0.8％。粪潜血及培养(-)。胃镜:上消化道粘膜苍白,食道贲门口炎症。病检:贲门慢
Male, 35 years old, miners. Hospital number 208030. To diarrhea, dizziness, fatigue, 10 months admitted to hospital. 10 months ago, after eating dirty unclear, abdominal pain, diarrhea 2-8 times a day, mucus, berberine and traditional Chinese medicine a month, anorexia, dizziness, fatigue gradually worsened. Swallowing obstruction in the past two months, vomiting, rectal prolapse, stool watery, brown, systemic failure, life can not take care of themselves. Physical examination: extremely poor nutrition, weight 36 kg, height 167 cm, apathetic, less lazy words, anemia appearance, dry skin, lower extremity edema, nervous system and other abnormal signs. Hb4.3g / mm ~ 3, WBC1190 / mm ~ 3, PC8000 / mm ~ 3, Ret0.8%. Occult blood and culture (-). Gastroscopy: upper gastrointestinal mucosa pale, esophageal cardia inflammation. Disease examination: cardia slow