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ID:50048493
大小:1.78 MB
页数:16页
时间:2020-03-02
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1、CasereportTheThirdWardofTheDepartmentofGastroenterologyTheThirdSectionofTheDepartmentofGastroenterologyMedicalRecordsforAdmissonMedicalNumber:Y1571532GeneralinformationName:XXXAge:TwentyOneSex:MaleRace:HanNationality:ChinaAddress:XinYang,Henan.Occupation:ExcavatordriverMa
2、ritalstatus:UnmarriedDateofadmission:Nov11th,2015Dateofrecord:8Pm,Nov11th,2015Complainerofhistory:patient’sfatherandhimselfReliability:ReliableChiefcomplaint:Reduplicatednauseaandvomitforsixandahalfmonths.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:Thep
3、atientfeltsuddennauseaandvomitedthefoodhetookinwithnorecognizablecauseaboutsixandahalfmonthsago.Hedidn’tpayattentiontoitandthoughthehadatesomethingwrong.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:Abouttwoweekslater,thenauseousandvomitorysymptomappeared
4、againandhefeltsourregurgitationandheartburnatthesametime.SohewenttothefirstaffiliatedhospitalofSuZhouUniversity.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:Theendoscopicexaminationshowedhehadduodenalulcersandrefluxesophagitis.Andthepathologicalreportoft
5、heulcerswaschronicinflammationwithproliferationoflymphocytes.ThentheRabeprazolewhichhadshowacurativeeffectwasgiventohim.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:Buttwomonthslaterafterthetreatment,theabove-mentionedsymptomappearedagainandbecamemoreser
6、ioussohewenttothefirstaffiliatedhospitalofSuZhouUniversityagainforfurtherthreatment.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:TheabdominalCT,MRIandMRCPallshowedthedilatationofthebileducts(boththeintra-hepaticandextrahepaticbiled-ucts)andthepancreaticd
7、ucts.Besides,theabdominalCTsho-wedtheenlargementofpancre-aswiththeprobabilityofpancr-eaticdivisum.Thenhewasdiag-nosedaspancreatitisandthesymptomatictreatmentwasappliedbuttheeffectwasnotcomfor-table.TheThirdSectionofTheDepartmentofGastroenterologyPresentillness:Sohewenttot
8、hefirstaffiliatedhospitalofZhengZhouUniversity.TheabdominalCTshowedtherewereso-meenlargedlymphno
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