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患者,男,72岁,因持续腹痛、恶心、呕吐2d入院。查体:体温36,0℃,呼吸24次/min,心率110次/min,血压95/60mmHg,轻度脱水貌,急性病容,左下肺闻及湿性罗音,心脏听诊未闻及病理性杂音,腹软,全腹压痛反跳痛,腹水征阴性,叩呈鼓音,肠鸣音0次/min。血常规示:WBC14.0×10~9/L,N80.4%,L19.6%。胸片示:左下肺炎。腹部透视示:肠腔扩张。拟诊(1)左下肺炎。(2)急性肠梗阻待排。予留观、禁食,补10%葡萄糖500m1,5%葡萄糖氯化钠1000ml,抗感染,胃肠减压治疗
The patient, male, aged 72, was hospitalized for 2 days because of persistent abdominal pain, nausea and vomiting. Physical examination: body temperature 36,0 ℃, breathing 24 times / min, heart rate 110 beats / min, blood pressure 95 / 60mmHg, mild dehydration appearance, acute disease, lower left lung smell and wet rales, cardiac auscultation and pathological noise , Abdominal soft, tender abdomen tenderness, ascites sign negative, knocking drum sounds, bowel sounds 0 times / min. Blood showed: WBC14.0 × 10 ~ 9 / L, N80.4%, L19.6%. Chest radiograph shows: left lower pneumonia. Abdominal perspective: Intestinal cavity expansion. To be diagnosed (1) left lower pneumonia. (2) Acute intestinal obstruction to be discharged. To stay view, fasting, make up 10% glucose 500ml, 5% glucose sodium chloride 1000ml, anti-infective, gastrointestinal decompression therapy