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蔡某,男,54岁,住院号2191.因饮酒上腹中部不适3天。呕血两次伴昏厥入院.平素身体健康.体检:T 36.5℃.P90次/分,R18次/分,Bp100/60.神清,贫血貌,未见蜘蛛痣、黄疸,浅表淋巴结未扪及,心肺无异常,未见腹壁静脉曲张和胃肠蠕动波,无压痛、反跳痛及包块,肝脾未触及,腹水征(-).Hb45g/L、WBC10.2×10~9/L、N76%,E2%、L22%,腹部 X 线检查无异常.入院诊断:急性上消化道出血(1)消化性溃疡,(2)出血性胃炎。即给予输血,补液、止血和抗溃疡治疗,每天仍有黑便,住院第7天再次发生呕血和解黑便及血便共约1500ml,急转外科行剖腹探查术.术
Cai, male, 54 years old, hospital number 2191. Because of drinking middle and upper abdominal discomfort for 3 days. Hematemesis twice with fainting hospitalization .In general health. Physical examination: T36.5 ℃ .P90 beats / min, R18 beats / min, Bp100 / 60. Shen clear, anemia appearance, no spider nevus, jaundice, superficial lymph nodes not palpable Hb45g / L, WBC10.2 × 10 ~ 9 / L, Hb45g / L, no signs of abdominal pain, , N76%, E2%, L22%, abdominal X-ray examination was normal. Admission diagnosis: acute upper gastrointestinal bleeding (1) peptic ulcer, (2) hemorrhagic gastritis. That is to give blood transfusion, rehydration, hemostasis and anti-ulcer treatment, there are still black every day, hospitalized again on the 7th day of hematemesis and resolve melena and bloody stool a total of about 1500ml, urgent surgical laparotomy.