English medical records of various departments collection of cardiology English medical records a Medical Records for Admisson Medical Number 701721General informationName Liu SideAge

No history of blood disorders. Endocrine system: No history of endocrine disorders. Nervous system: No history of neurological disease. Musculoskeletal system: No history of musculoskeletal disorders. Skin: No history of skin diseases. Psychiatric history: No history of psychiatric illness. Family history: No family history of major diseases.

Physical examination: Vital signs: Blood pressure 80/50mmHg, pulse 110 beats/min, respiratory rate 24 breaths/min, temperature 36.5℃. General appearance: The patient is weak and pale, with cold sweat. Skin: No rash or lesions. Head and neck: No swelling or tenderness of lymph nodes, no deformity of skull or face. Chest: Clear breath sounds, no rales or wheezes. Cardiovascular system: Rapid heart rate, regular rhythm, no murmur. Abdomen: Upper abdominal tenderness, no rebound tenderness or guarding. The liver and spleen are not palpable. Neurological system: The patient is unconscious, with no response to stimuli.

Diagnosis: Upper gastrointestine hemorrhage, exsanguine shock, unconsciousness.

Treatment:

1. Stabilize vital signs: IV fluid resuscitation, oxygen therapy, blood transfusion.
2. Upper gastrointestinal endoscopy: Reveal active bleeding at the gastric fundus, multiple gastric ulcers.
3. Symptomatic treatment: Proton pump inhibitors, antibiotics, hemostatic drugs.
4. Nutritional support: Enteral nutrition.

Prognosis: The patient's condition is critical, and the prognosis is uncertain. The patient is still in a coma and needs continuous monitoring and treatment