病历摘要患者,男性,52岁。因慢性腹泻8个月、间断呕吐3个月,于1991年3月22日入院。缘于1990年6月无明显诱因出现大便次数增多,每日3～4次,黄色稀便,无脓血,无粘液及脂肪样外观,内含不消化食物。无发热、腹痛及里急后重,无四肢关节疼痛,无盗汗及午后潮热,无咳嗽、咳痰。4个月后逐渐出现纳差、呕吐,呕吐物为胃内容物,偶为隔夜宿食,每日1～2次。自发病以来,逐渐消瘦,体重下降15kg。以往无其它疾病史。体格检查:消瘦,慢性病容,贫血貌,毛发枯黄,浅表淋巴结不大,皮肤无皮疹、出血点,无皮下结节,无肝掌及蜘蛛痣,巩膜无黄染。口角溃疡,舌质红,舌体小,无苔,乳突消失,舌边缘有散在小溃疡。颈软,甲状腺不大。心肺未见异常。腹平软,无压痛,未及包块,肝脾未及,移动性浊音阴性。外生殖器及肛门无异常。生理反射存在,病理反射未引出。实验室检查:血红蛋白56g/L,血白细胞4.7 Patient summary, male, 52 years old. 8 months due to chronic diarrhea, intermittent vomiting for 3 months, on March 22, 1991 admission. As a result of June 1990 there was no obvious incentive to increase the number of stool, 3 to 4 times a day, yellow loose stools, no abscess, no mucus and fat-like appearance, containing indigestible food. No fever, abdominal pain and tenesmus, no limb joint pain, no night sweats and night sweats, no cough, sputum. 4 months after the gradual emergence of anorexia, vomiting, vomit stomach contents, even overnight overnight food, 1 or 2 times a day. Since the onset, gradually weight loss, weight loss 15kg. In the past no other history of disease. Physical examination: weight loss, chronic disease, anemia appearance, hair yellow, superficial lymph nodes, skin rash, bleeding points, no subcutaneous nodules, liver palms and spider nevus, sclera no yellow dye. Mouth ulcers, red tongue, small tongue, no moss, mastoid disappeared tongue edge scattered small ulcers. Soft neck, small thyroid. Heart and lung no abnormalities. Abdomen soft, no tenderness, and mass, liver and spleen yet, mobility dullness negative. Genitals and anus without exception. Physiological reflex exists, the pathological reflex did not lead. Laboratory tests: hemoglobin 56g / L, white blood cells 4.7