Name:xxicccccccGender:maleAge:xxxPatients’identificationnumber:xxnnnxx

Unitoraddress:xxxxxx,xxxxxxxxdistrict,xxxxxCity

Briefingofpatients’condition:Yesterday,thepatientsufferedfromparoxysmalabdominalcolicwithoutradiatingpain,sufferedfromwaterystoolsixtimeswithnausea,sufferedfromvomitingbetweensixtoeighttimes,whichiswaterycontentandgastriccontent,withouthaematemesisandtarrystool.Thepatientfeltdizzyandlanguid.Thepatientdidn’thaveheadache,sweatingandfeversymptoms.Thepatienthadanormalurinatingwithoutchestdistressandpalpitation.Thepatientdidn’thavetic,unconsciousnessandgatismsymptoms.Physicalexamination:T:37.1℃P:80timesperminR:20timesperminBP:130/70mmHg.Thepatientisconscious,notlookingdehydrated,withsoftabdomenandpressingpainonthemiddleofbellybuttonandwithoutreboundtenderness.Hisbowelsoundisslightlyhyper-functionalatbetweenseventoeighttimespermin.Bloodroutine:WBC17.8x109/LN83.9%.Stoolroutine:WBC:8-10/HPFWithoutmucusandpusandblood.

Admittingdiagnosis:

1.Chronicsuperficialgastritis.

Treatmentsuggestions:

1.Spasmolysis,symptomatic,anti-infectionandfluidinfusiontreatment;

2.Nurseone’shealthbytakingtraditionalChinesemedicineandcycletherapy;

3.Quietrest,payattentiontodietandseeadoctorwhenfeelinguncomfortable.

TheThirdPeople’sHospitalofxxxxxCity

Dedicatedstampfordiseasediagnosis