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吕××,男,46岁,农民,于1979年4月9日入院,住院号17712。患者从1978年11月份开始,大便呈棕褐色,每天一次,自觉进食后胃脘部有灼热感,无反酸嗳气,此后头昏乏力,活动后心慌气短,大便始终为棕褐色。近年来上述症状日益加重。既往无上腹痛、反酸及便血史。体格检查:体温36.9℃,脉搏70次,呼吸19次,血压110/60毫米汞柱,一般情况欠佳,贫血貌,神志清楚,巩膜不黄,两侧瞳孔等大,舌质淡,颈软,右上肺部呼吸音
Lu XX, male, 46 years old, farmer, was admitted on April 9, 1979 with a hospital number of 17712. Patients from November 1978 onwards, the stool was brown, once a day, consciously eat stomach after a fever, no acid reflux, then dizzy and fatigued, palpitation shortness of breath after activities, the stool is always brown. In recent years, the above symptoms are getting worse. No previous abdominal pain, acid reflux and history of blood in the stool. Physical examination: body temperature 36.9 ℃, pulse 70 times, breathing 19 times, blood pressure 110/60 mm Hg, poor general condition, anemia appearance, consciousness, sclera not yellow, bilateral pupils and other large, pale tongue, neck soft , Upper right lung breath sounds