Previous medical history of gastric ulcer, drug allergy, no others, you can fill in the date of treatment yourself

Fill in the department of gastroenterology at the hospital you visited

Main complaint: upper abdominal distension and pain, With black stool for 3 weeks

History of current illness: Unexplained epigastric distension and pain occurred 3 weeks ago, which was paroxysmal, mainly under the xiphoid process, with black stool 2 times, with a volume of about 30ml , accompanied by dizziness, dizziness, weakness, acid reflux, nausea and vomiting, and vomiting of stomach contents without vomiting blood. No action was taken at that time. It has been postponed to this day. The patient had no fever, no chills or fever, no sputum, no chest tightness and shortness of breath, no syncope, poor spirit and appetite, and normal urine.

Past history: Diagnosed with chronic gastritis in 2008, gastric ulcer in 2010, no history of hypertension, hepatitis, tuberculosis, no history of drug allergy,

Major trauma Surgery history: None

Personal history: No bad living habits.

Menstrual history of marriage and childbearing: unmarried, normal menstruation

Family history: There is no genetic history among family members.

Physical examination

T36.50C P92 times/min R 18 times/min Bp96/71mmHg Normal development, poor nutrition, painful expression, acute facial appearance, conscious, no yellow skin and mucous membranes Stained, pale conjunctiva, pale complexion, no swollen lymph nodes. There was no deformity of the head, regular facial features, pharyngeal congestion (-), no enlargement of tonsils, no suppuration, and no follicular hyperplasia. The neck was soft and without resistance, the trachea was in the middle, the thyroid was not enlarged, there was no vascular murmur, there was no deformity of the thorax, the voice and vibrato were even and strong in both lungs, the breath sounds in both lungs were clear, the percussion was voiceless, and no wet or dry rales were heard. There was no bulge in the precordium, normal apical pulse, no tremor, HR 92 beats/min, regular rhythm, strong heart sounds, no murmurs. Abdomen was flat, subxiphoid tenderness +-, no rebound tenderness, liver and spleen not palpable, intestines Chirps 4-5 times/min, no shifting dullness. The anus, rectum, and external genitalia were not examined. There were no deformities in the limbs and spine. Physiological reflexes were present, and no pathological reflexes were elicited.

Auxiliary examination: Routine blood test: WBC: 7.5*10*9/L, HGB: 87g/L, RBC: 2.86*10*12/L, HCT: 26.8%.

Preliminary diagnosis: 1. Upper gastrointestinal bleeding

2. Hemorrhagic anemia

Treatment opinions: anti-inflammation, hemostasis, protection of gastric mucosa, and supportive symptomatic treatment

Admission to hospital

Physician’s signature: xxx