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病历摘要患者何某,女,26岁,农民。主诉头昏、乏力、腹部隐痛半个月,便血2天于1982年12月3日入院。患者平素身体健康。于入院前半个月开始头昏、乏力、纳差,并感腹部隐痛,自觉无明显发热。3天前开始解稀便,但无脓血,至12月2日突然解水样血便3次,每次约100ml,入院当天又解7次,每次约300～500ml,为暗红色血便(部份为肠内容物),混有血块,但无明显腥臭。门诊诊断下消化道出血,原因待查,收入外科病房治疗。体格检查:体温38℃,脉搏102次,血压80/40。发育营养中等,贫血面容,神志清楚,表情淡漠,巩膜无黄染,表浅淋巴结不肿大,无皮疹,颈软,心肺无特殊发现,腹部平坦、柔软,脐周有轻度压
Hemou, patient, 26 years old, farmer. Chief complaint dizziness, fatigue, abdominal pain half a month, two days of blood in the stool was admitted on December 3, 1982. Patients usually healthy. Half a month before admission, dizziness, fatigue, anorexia, and abdominal pain, consciously no obvious fever. 3 days ago began to relieve loose stools, but no pus and blood, to December 2, suddenly relieved watery blood 3 times, each about 100ml, on the day of admission again 7 times, each about 300 ~ 500ml, dark red bloody stool Part of the intestinal contents), mixed with blood clots, but no obvious stench. Outpatient diagnosis of lower gastrointestinal bleeding, to be investigated, income surgical ward treatment. Physical examination: body temperature 38 ℃, pulse 102 times, blood pressure 80/40. Development of moderate nutrition, anemia, consciousness, apathy, scleral no yellow dye, superficial lymph nodes are not swollen, no rash, neck soft, no special cardiopulmonary findings, abdominal flat, soft, mild pressure on the umbilical