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患者女性,39岁,农民。近半年来头晕加重,乏力,纳差,上腹饱胀且隐痛。3个月前因柏油样便,当地医院按上消化道出血治疗后好转。入院2天前呕血3次,约1200ml,再次黑便呈柏油样而急转我院。查体:血压12/8kPa,神清,精神差,重度贫血貌,颈软,肺(-)。心率98次/分,律齐,腹软,肝脾未触及,中上腹有压痛。实验室检查:Hb40g/L,RBC1.3×10~(12)/L,WBC4.2×10~9/L,N0.60,L0.40,BPC90×10~9/L,大便隐血(+)。入院诊断:(1)上消化道出血。(2)消化性溃疡。治疗:止血、输血,住院10天输血4次,共1800ml,预防感染及支持疗法。住院11天,大便隐血(-),带药(铁剂)出院。出院后,仍面黄、头晕、纳差、腹痛而去外地某医学院进一步诊治,诊断
Female patient, 39 years old, farmer. Dizziness increased in the past six months, fatigue, anorexia, abdominal pain and fullness. 3 months ago due to tarry stool, the local hospital according to upper gastrointestinal bleeding after treatment improved. 2 days ago admitted to hematemesis 3 times, about 1200ml, once again black asphaltene and acute hospital. Physical examination: blood pressure 12 / 8kPa, God clear, poor spirit, severe anemia, neck soft, lung (-). Heart rate 98 beats / min, law Qi, abdominal soft, liver and spleen not touched, tenderness in the upper abdomen. Laboratory tests: Hb40g / L, RBC1.3 × 10-12 / L, WBC4.2 × 10-9 / L, N0.60, L0.40, BPC90 × 10-9 / L, occult blood stool + ). Admission diagnosis: (1) upper gastrointestinal bleeding. (2) peptic ulcer. Treatment: hemostasis, blood transfusion, blood transfusion in 10 days 4 times, a total of 1800ml, prevention of infection and supportive therapy. Hospitalized for 11 days, stool occult blood (-), with medicine (iron) was discharged. After discharge, still yellow, dizziness, anorexia, abdominal pain and go to a medical school for further diagnosis and treatment