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病历摘要男患,12岁,学生,因上腹疼痛伴腹泻1年余入院、缘于1年前未明显出现上腹部疼痛.疼痛表现为周期性反复发作,即上腹疼发作持续几天,继之为10～20天的缓解,近几个月发作频繁.持续时间延长,缓解期缩短.疼痛有时发生于二餐之间,有时发生在餐后l小时左右.疼痛部位多在剑突下或中上腹部,疼痛多为钝痛,有时是烧灼样疼,疼痛可因疲劳、气候变化、饮食不当而诱发或加重,休息、服抗酸药或以手按压常可使疼痛缓解、病后有水样腹泻,每天3～5次不等.有时反酸暧气、疲劳无力、口渴.既往有肾结石病史.生于本地,家族中其他成员无类似病史.查体:体温 :37℃,脉搏58次/分,呼吸20次/分,血压12/8kPa.神志清,发育营养中等.皮肤粘膜无黄染,无出血点,全身淋巴结未触及.胸廓无畸形,双肺呼吸音清.心率58次/分,心音有力,未闻及早搏及病理性杂音.腹平坦、软,无明显压痛,肝、脾未触及,肠鸣音存在,无增强及减弱、肾区无叩击痛、
Medical history Abstract Male patient, 12 years old, was admitted to hospital due to abdominal pain with diarrhea more than 1 year, due to the fact that upper abdominal pain did not appear obviously 1 year ago.The recurrence of the pain was periodic, Followed by 10 to 20 days of relief in recent seizures frequent prolonged duration of remission to shorten the pain sometimes occurs between two meals, and sometimes occurs in the postprandial l hour or so painful sites in the xiphoid Or in the upper abdomen, the pain is mostly dull pain, sometimes burning like pain, pain may be due to fatigue, climate change, improper diet induced or aggravated, rest, taking antacid or hand pressure can often relieve pain, illness There are watery diarrhea, 3 to 5 times a day.Some acid reflux, fatigue, thirst.Previous history of kidney stones .Born in the local, other members of the family without a similar history .Check the body temperature: 37 ℃ , Pulse 58 beats / min, breathing 20 beats / min, blood pressure 12 / 8kPa. Sense of clear, the development of nutrition is moderate. Skin mucosa no yellow dye, no bleeding point, body lymph nodes not touched. Heart rate 58 beats / min, strong heart sounds, no premature beat and pathological murmur.Flat flat, soft, no significant tenderness, Liver, spleen not touched, bowel sounds exist, no enhancement and weakened, no perineal pain,