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急性肠胃炎大病历范文# 急性肠胃炎大病历。
一、基本信息。
姓名：[具体姓名]性别：[男/女]年龄：[X]岁。
职业：[具体职业]联系电话：[电话号码]住址：[详细住址]二、主诉。
“大夫啊，我这肚子痛得要命，还一个劲儿地拉肚子，从昨天就开始了，实在是受不了啦！”三、现病史。
患者于昨日上午开始出现腹部不适，最初是隐隐作痛，没太在意，以为是早上吃凉东西了，过会儿就能好。
谁知道这疼痛越来越厉害，就像肚子里有个小怪兽在捣乱似的。
中午吃了点东西后，就开始跑厕所，拉出来的都是稀水样便，一下午就跑了七八趟。
而且还恶心，感觉胃里翻江倒海的，吃进去的东西都往上涌，但是吐也没吐出多少东西来。
到了晚上，肚子痛得更厉害了，一阵一阵地绞痛，疼得直冒冷汗，根本就没法睡觉。
今天早上起来，还是拉个不停，整个人都没力气了，感觉像被抽干了一样。
这期间也没敢乱吃东西，就喝了点温水，可还是难受得不行，这才赶紧来医院了。
四、既往史。
患者既往身体还算不错，就是有时候会有点小感冒，吃点药就好了。
没有高血压、糖尿病这些慢性病。
不过患者说自己平时吃饭不太规律，忙起来就顾不上吃饭，有时候又会暴饮暴食，还特别爱吃辣的和凉的东西。
去年也有过一次肚子疼拉肚子的情况，但没这次这么严重，当时自己吃了点止泻药就好了。
五、个人史。
患者不抽烟，偶尔会喝点酒，但是酒量不大。
平时工作比较忙，经常加班，缺乏运动。
居住环境还可以，没有什么特殊的情况。
六、家族史。
家族里没有遗传性疾病，父母身体都比较健康，兄弟姐妹也都没有类似的胃肠道疾病。
七、体格检查。
1. 一般情况。
患者神志清楚，但是精神萎靡，面容有些苍白，看起来很疲惫的样子。
体温：37.8℃，有点低热，摸额头就能感觉到有点烫。
血压：110/70 mmHg，基本正常。
脉搏：90次/分，稍微有点快，可能是因为身体不舒服的原因。
2. 腹部检查。
视诊：腹部平坦，没有看到明显的膨隆或者凹陷，但是患者一直皱着眉头，手捂着肚子，看得出来肚子很疼。
急性胃肠炎病历范文英文回答：Acute gastroenteritis is a common condition characterized by inflammation of the stomach and intestines. It is usually caused by a viral or bacterial infection, and can result in symptoms such as nausea, vomiting, diarrhea, abdominal pain, and fever. In my case, I recently experienced a bout of acute gastroenteritis and sought medical attention.I woke up one morning feeling extremely nauseous andhad an intense urge to vomit. I rushed to the bathroom and ended up emptying my stomach. The vomiting continued throughout the day, accompanied by watery diarrhea. It wasa terrible experience as I felt weak and exhausted. Icouldn't keep anything down, not even water. The abdominal pain was also unbearable, making it difficult for me to move around.I decided to visit my doctor who diagnosed me with acute gastroenteritis. He explained that it was most likely caused by a viral infection, possibly from contaminated food or water. He prescribed me medication to help control the vomiting and diarrhea, and advised me to drink plenty of fluids to prevent dehydration.Over the next few days, I followed my doctor's advice and took the prescribed medication. I also made sure to drink lots of water and consume electrolyte-rich fluidslike sports drinks and coconut water. Gradually, the symptoms started to improve. The vomiting and diarrhea became less frequent, and the abdominal pain subsided. I also regained my energy and was able to resume my normal activities.During this time, I had to be careful with my diet. I avoided spicy and greasy foods, as they could irritate my stomach. Instead, I opted for bland and easily digestible foods like rice, boiled potatoes, and toast. I also included probiotic-rich foods like yogurt to help restore the balance of good bacteria in my gut.It took about a week for me to fully recover from acute gastroenteritis. The experience was unpleasant, but I learned the importance of proper hygiene and food safety. I now make sure to wash my hands regularly, especially before eating, and to consume only properly cooked and hygienic food.中文回答：急性胃肠炎是一种常见的疾病，其特征是胃肠道的炎症。
急性胃肠炎病历范文英文回答：I recently had a case of acute gastroenteritis in my medical practice. The patient, a 35-year-old male, came to me complaining of severe abdominal pain, nausea, vomiting, and diarrhea. Upon further inquiry, he revealed that he had eaten at a local fast food restaurant the previous night.Upon physical examination, the patient appeared pale and dehydrated. His vital signs were stable, with aslightly elevated temperature. Abdominal examination revealed tenderness in the lower quadrants. Based on the patient's symptoms and history, I suspected a case of acute gastroenteritis.To confirm the diagnosis, I ordered a stool sample analysis. The results showed the presence of white blood cells and increased levels of fecal leukocytes, indicating an inflammatory response in the gastrointestinal tract.Additionally, the stool culture revealed the presence of Campylobacter jejuni, a common bacterial cause of gastroenteritis.Treatment for acute gastroenteritis typically involves supportive care, as the condition is usually self-limiting.I advised the patient to maintain hydration by drinking plenty of fluids and recommended an oral rehydration solution to replace lost electrolytes. I also prescribed an antiemetic to relieve his nausea and vomiting.In addition to symptomatic treatment, I educated the patient about proper hand hygiene and food safety practices to prevent the spread of the infection. I emphasized the importance of washing hands thoroughly with soap and water before handling food and after using the toilet. I also advised him to avoid consuming undercooked or contaminated food.The patient's symptoms gradually improved over the next few days, and he reported a decrease in abdominal pain, vomiting, and diarrhea. He followed the prescribedtreatment plan and made sure to practice good hygiene and food safety measures. After a week, he made a full recovery and returned to his normal activities.中文回答：最近在我的医疗实践中遇到了一例急性胃肠炎的病例。
2016年8月16日14时30分首次病程记录之樊仲川亿创作患者韦美丽，女性，53岁。
因腹痛、腹泻1天于2016年8月16日14时30分自行入院。
一、病例特点：1、患者中年女性，以腹痛、腹泻为主要症状，伴呕吐，有食用街边快餐及饮用冷冻水等不洁饮食史。
2、患者1天前出现阵发性上腹部绞痛，无放射痛，解水样大便6次，伴恶心，呕吐6-8次，为胃内容物及水样物，无呕血及黑便。
伴头晕、全身无力。
无头痛，无出汗，无发热。
无胸闷、心悸，小便正常。
无抽搐，无意识不清，无尿便失禁。
精神一般。
曾外院门诊就诊，给予口服药物（具体不详）治疗后仍有恶心、呕吐，伴随腹泻、腹胀，无发热。
3、既往体健。
未发现药物、食物过敏史。
0C，P：80次/分，R：20次/分，BP：130/70mmHg。
神志清楚，无脱水貌，查体合作。
瞳孔等大等圆，直径约3.00mm，对光反射灵敏。
双肺呼吸音清，未闻及干湿性罗音。
心率80次/分，律齐，无杂音。
腹软，脐周部正中压痛，无反跳痛，麦氏点无压痛。
肠鸣音稍亢进，约7-8次/分。
生理反射存在，病理反射未引出。
×109/L，N 83.9％。
便惯例：WBC：8-10/HPF，无粘液及脓血。
二、初步诊断：急性胃肠炎三、诊断依据：1、患者中年女性，以腹痛、腹泻伴随呕吐为主要症状，有不洁饮食史。
0C，BP：130/70mmHg。
神志清楚，无脱水貌，体查合作。
腹软，脐周部正中压痛，无反跳痛，肠鸣音稍亢进，约7-8次/分。
×109/L，N 83.9％。
便惯例：WBC：8-10/HPF。
四、鉴别诊断：1、急性胰腺炎：两病均有腹痛症状，但急性胰腺炎者腹痛更剧烈，以左上腹为主，伴随呕吐，发热。
大多数有暴饮暴食史，一般无腹泻症状。
需要时查血、尿淀粉酶及腹部CT明确病情。
2、急性阑尾炎：部分急性阑尾炎者可以腹痛、腹泻为首发表示，但腹痛以右下腹为主，或者伴随转移性右下腹痛。
该患者腹痛以脐周正中为主，无转移性右下腹痛，麦氏点无压痛。
急性胃肠炎病历范文英文回答：Acute gastroenteritis, also known as stomach flu, is a common condition characterized by inflammation of the stomach and intestines. It is usually caused by a viral or bacterial infection, and can result in symptoms such as nausea, vomiting, diarrhea, abdominal pain, and fever. In severe cases, dehydration may occur.I recently experienced a case of acute gastroenteritis and it was quite unpleasant. I woke up one morning feeling nauseous and soon started vomiting. I also had diarrhea and my stomach was in a lot of pain. It was a really uncomfortable experience and I couldn't eat anything without feeling even worse.I went to see a doctor who diagnosed me with acute gastroenteritis. He prescribed some medication to help with the symptoms and advised me to drink plenty of fluids toprevent dehydration. He also recommended that I stick to a bland diet until my stomach settled down.Over the next few days, I followed the doctor's advice and took the medication as prescribed. I also made sure to drink lots of water and electrolyte-rich drinks to stay hydrated. I avoided spicy and greasy foods, opting forplain rice, boiled potatoes, and toast instead. It took some time, but gradually my symptoms started to improve. The vomiting and diarrhea stopped, and my stomach pain subsided.During this time, I also learned the importance of good hygiene practices to prevent the spread of gastroenteritis.I made sure to wash my hands thoroughly and frequently, especially before preparing food or eating. I also avoided close contact with others to avoid spreading the infection.Overall, my experience with acute gastroenteritis was not pleasant, but with proper medical care and self-care, I was able to recover. It reminded me to take care of my health and practice good hygiene to prevent such infectionsin the future.中文回答：急性胃肠炎，也被称为胃肠流感，是一种常见的疾病，其特征是胃肠道的炎症。
