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1、MedicalRecordsforAdmissionMedicalNumber:701721GeneralinformationName:YuChangshengOccupation:UnknownAge:FortyeightMaritalstatus:MarriedSex:MaleDateofadmission:14:21,July9th,2010Race:HanDateofrecord:17:10,July9th,2010Nationality:ChinaComplainerofhistory:Patient’shimselfAddress:NO.168,Baodon
2、gRoad,Shanghai.Reliability:ReliableChiefcomplaint:Epigastricdiscomfortforonemonth,melenaforfivedays.Presentillness:Thepatientfeltepigastricdiscomfortaboutonemonthagowithoutanyreasons.Andfoundmelena5daysago.Pitch-like,shaping,frequencyisnormalwithoutabdominalpain,sourregurgitation,nauseaan
3、dvomiting.Becausethepatienthadhemorrhoids,sohedidnotpaymuchattention.2010/7/9,thepatientfeltanergy,weakness,coldsweat,andsawthedoctor12intheemergencyward.TheBPwas80/60mmHg,BRT:RBC3.7*10/L,9Hb108g/L,WBC4.9*10/L,N%67.3%.ThedoctorconsidereditwashemorrhageofupperdigestivetractandgavehimOmepra
4、zole40mgintravenouspushandantiinflammation,fluidreplacement.Thepatientfeltbetter.Thenextdaygastroscopeshowedgastricangleulcer,chronicgastritis.Sothepatientwasadmittedtoourwardforfurthertreatment.Duringthecourse:Generalstatusnormal.Spirit,sleep,appetitenormal.Urinenormal.Theweightlost10Kg.
5、PasthistoryAhistoryofpepticulcerandhemorrhoids.Nohistoryofinfectivediseases.Nohistoryofoperationortrauma.Nobloodtransfusionhistory.Noallergyhistory.PersonalhistoryHewasbornandlivedinShanghai.Ahistoryofsmokingfor30years.Noexposurehistorytoepidemicareaofinfectiousdisease.Familyhistory:Hisfa
6、therwasdiedofstrokeandmotherwasdiedofcancer.Hischildrenwashealthy.Nocommunicablediseasesandgeneticdisease.PhysicalexaminationT37℃,P80/min,R20/min,BP110/70mmHg.Hewaswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasclear.Hisfacewaspaleandtheskinwasnotstainedyellow.Nocya
7、nosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Superficiallymphnodeswerenotfoundenlarged.Respiratorymovementwasbilaterallysymmetricwiththefrequencyof20/min.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsound.Nowheezes.Noral
