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患者马××,男,46岁,住院号92573,于1963年5月7日饭后腹上部疼痛八个月、进行性吞咽困难三个多月为主诉入院。自称八个月前每当进硬食后,觉腹上部疼痛;发病后一月,饮水亦疼痛。五个月后,进食腹上部疼痛更重,同肘伴有阻挡感,且不能进硬食,只能吃些稀软食物如面条等。近两月来,吞咽困难加重,稀软食物亦难咽下,但无呕吐现象。并有背部疼痛,体重明显下降。经中度按“胃病”治疗无效。患者平日喜饮少量白干酒,迸食快。其父母均患“噎食病”,于8年前双亡。检查:营养差,消瘦,慢性病容。全身淋巴结不胀大。心肺(-)。腹部、脊柱及四肢均无特异。化验:血红蛋白11克,红细胞420万。大小便常规
Patient Ma × ×, male, 46 years old, hospital number 92573, on May 7, 1963, abdominal pain after eating eight months, progressive dysphagia more than three months as the main admission. After eight months of self-proclaimed hard food, she felt pain in the upper abdomen; in the month after onset, drinking water was also painful. Five months later, the pain in the upper part of the abdomen was heavier, and there was a feeling of obstruction in the same elbow, and hard food was not allowed. Only some soft food such as noodles could be eaten. In the past two months, dysphagia has increased, and soft and soft foods have been difficult to swallow, but there is no vomiting. And there is back pain and body weight dropped significantly. After moderately “stomach” treatment is ineffective. Patients usually drink a small amount of white dry wine on weekdays and eat fast. His parents suffered from “feeding sickness” and died twice 8 years ago. Check: poor nutrition, weight loss, chronic disease. Whole body lymph nodes do not swell. Cardiopulmonary (-). There are no specificities in the abdomen, spine and limbs. Laboratory tests: 11 grams of hemoglobin and 4.2 million red blood cells. Urine routine