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贾××,男,42岁,×矿工人,病历号25604。初诊1982年11月25日。腹痛、腹泻二年余。患者二年多来经常腹痛,腹泻时轻时重,大便溏稀,一日4~5次,食少、倦怠,身体日渐消瘦。曾经中西医多方医治无效,因不能坚持工作而休病假一年多。近日腹泻加重而来本科门诊就医,病人面色枯褐,舌体胖,苔白厚,脉沉细。检查:白血球总数13500/立方毫米,中性74%,淋巴26%。大便镜检:红细胞少许,
Jia X, male, 42 years old, x miner, medical record number 25604. First visit November 25, 1982. Abdominal pain, diarrhea more than two years. The patient often has abdominal pain for more than two years. When diarrhea is light and heavy, the stool is loose and thin. Four to five times a day, eating less, being tired, the body is becoming thin. Once many Chinese and Western medicine doctors were ineffective, because they couldn’t keep working for more than one year. In recent days, diarrhea aggravated and came to the undergraduate clinic for treatment. The patient looked withered brown, tongue fat, thick white coating, and thin pulse. Check: The total number of white blood cells is 13500/mm3, 74% neutral, and 26% lymph. Stool microscopy: a little red blood cells,