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病历摘要 男性,63岁,教师,因腹泻、便秘交替,消瘦6个月于1984年9月22日入院。1984年2月开始感上腹不适伴腹泻,每日2～4次,黄稀便。3月份曾作钡餐检查未发现异常。从4月开始腹泻、便秘交替发生,并食欲减退及厌油,逐渐消瘦,体重减轻约10kg。核素肝扫描无占位性病变,肝功能正常。HBsAg(-)。至9月份出现腹水,在某院诊断为“结核性腹膜炎与肠结核”,经抗痨治疗腹水消失,但腹泻仍持续,每日2～7次。以往身体健康,无饮酒嗜好,吸烟30余年,日约1包。本人与家族中无胃肠与肝病史。 体格检查:体温37.8℃,脉搏75次,呼吸24次,血压120/95,身体明显消瘦,体重35.5kg,皮肤无出血点与蜘蛛痣,无肝掌,周围淋巴结肿大(约2x3cm),质中,无压痛。巩膜轻度黄染,心肺无异常。腹壁平坦,柔软,脐周轻度压痛,无反跳痛。肝于肋下1.5cm,质中,无压痛,脾未触及。转移性浊音(-),肠鸣音频率与声调正常,指肛检查无异常。 实验室检查:血红蛋白12.3g/dl,红细胞800万,白细胞11000,中性88％,大便潜血阴性;血钾2.8mEq/
Medical records summary Male, 63 years old, a teacher, admitted to hospital on September 22, 1984, 6 months of weight loss due to alternating diarrhea and constipation. In February 1984, she began to feel upper abdominal discomfort with diarrhea, 2 to 4 times a day, yellow loose stools. No abnormalities were found during the barium meal inspection in March. From April onwards, diarrhea and constipation occurred alternately, and loss of appetite and tiredness of the oil gradually led to weight loss of approximately 10 kg. There was no space-occupying lesions in the nuclide liver scan and normal liver function. HBsAg(-). Ascites occurred in September and was diagnosed as “tuberculous peritonitis and intestinal tuberculosis” in a hospital. The ascites disappeared after antispasmodic treatment, but diarrhea persisted, 2 to 7 times a day. In the past, he was physically fit, had no drinking habits, smoked for more than 30 years, and was about 1 packet per day. There is no history of gastrointestinal and liver diseases in my family and family. Physical examination: body temperature 37.8°C, pulse 75, breathing 24 times, blood pressure 120/95, body weight loss, weight 35.5kg, skin without bleeding spots and spider mites, liver without palm, peripheral lymph nodes (about 2x3cm), quality In the absence of tenderness. The sclera is yellowishly stained and there is no abnormality in the heart and lungs. Abdominal wall is flat, soft, mild tenderness around the umbilical cord, no rebound tenderness. The liver was 1.5 cm below the ribs. In the mass, there was no tenderness and the spleen was not touched. Transient dullness (-), bowel sound frequency and tone normal, no abnormalities of the anal examination. Laboratory examination: hemoglobin 12.3g/dl, red blood cells 8 million, white blood cells 11000, neutral 88%, fecal occult blood negative; blood potassium 2.8mEq/