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女患,52岁,住院号790011。因上消化道大出血休克急诊入院。4天前开始呕血及便血,入院当日头晕摔倒。既往无“胃病”史,因偏头痛连续服用APC已两年。体检:体温37.6℃,脉搏116次/分,血压86/58毫米汞柱,神清合作,贫血貌,中度脱水,浅淋巴结不大,黄疸(一),心肺听诊无杂音,肺肝界于右乳线第六肋间,腹软,舟状,胃型(一),畅型(一),腹壁静脉曲张(一),肝脾不大,剑突下压痛(+),抵抗(一),反跳痛(+),包块(一),腹水(一),脊柱四肢神经系统无异常。化验:血红蛋白32％,白细胞
Female patient, 52 years old, hospital number 790011. Hemorrhagic shock due to upper gastrointestinal emergency admission. 4 days ago hematemesis and blood in the stool, dizziness fell on the day of admission. Past no “stomach” history, due to migraine headache taking APC for two years. Physical examination: body temperature 37.6 ℃, pulse 116 beats / min, blood pressure 86/58 mm Hg, Shenqing cooperation, anemia appearance, moderate dehydration, light lymph node is not large, jaundice (a), cardiopulmonary auscultation without noise, Breast line sixth intercostal, abdomen soft, scaphoid, gastric type (a), smooth type (a), abdominal varicose veins (a), hepatosplenism, tenderness under the xiphoid (+ Rebound tenderness (+), mass (a), ascites (a), spinal nerve system without abnormalities. Assay: Hemoglobin 32%, white blood cells