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病历摘要男性,55岁。上腹部隐痛不适2个月,黑粪2天。患者2个月前开始出现上腹部隐痛不适,进食后明显,伴饱胀感,食欲逐渐下降,无明显恶心,无呕吐或呕血。曾到当地医院就诊,按"胃炎"进行治疗(用药不详),自觉稍好转。但全身状态不如以前,疲倦、乏力,消瘦,体重较发病前下降5千克,近2天发现粪便色黑,来院就诊,查2次粪隐血(+),末梢血WBC5.1×10/L,Hb90g/L,为进一步诊治收入院。既往史:身体健康,无胃病、肝病史,吸烟20年,10支/天左右。父亲死于"消化道肿瘤"(具体不详)。查体:一般情况尚可,皮肤无黄染,锁骨上窝及其他浅表部位未触及肿大淋巴结,结膜苍白,心肺未见异常。腹平坦,未见胃肠型或蠕动波,腹软,肝脾肋下未触及,未触及包块,剑突下有深压痛,移动性浊音(-),肠鸣音正常,直肠指诊未发现异常。辅助检查:腹部B超检查未见肝脏病变。上消化道造影显示胃窦小弯侧有约2cm大小龛影,位于胃轮廓内,周围黏膜僵硬粗糙,皱襞中断。要求:根据以上病历摘要,请写出初步诊断及诊断依据、鉴别诊断、进一步检查与治疗原则。

答案

参考答案:

初步诊断及诊断依据

初步诊断:1.上消化道出血2.胃癌3.失血性贫血

诊断依据:1.病史中有典型的临床表现:腹痛、黑粪、乏力、食欲缺乏、消瘦,呈渐进性过程。2.查体:结膜苍白,剑突下深压痛。3.辅助检查:上消化道造影显示胃内龛影,周围黏膜僵硬粗糙。粪便隐血(+),血红蛋白降低(Hb90g/L)。

鉴别诊断:1.胃溃疡2.胃部其他肿瘤并发出血

进一步检查:1.首选胃镜检查,同时取组织标本,病理检查。2.腹部CT检查。

治疗原则:1.一般治疗:控制饮食,注意休息,做好术前准备。2.开腹探查,胃癌根治术,若不能彻底根治,也要争取切除胃部病变,缓解失血情况。3.术后应进行辅助化疗。

问答题 简答题
问答题

James Shapiro follows his award-winning book on William Shakespeare, 1599, which came out in 2005, with an unlikely subject: an investigation into the old chestnut that Shakespeare wasn’t the man who wrote the works.

Most mainstream Shakespeareans stand aloof from it. But apparently the claims of Francis Bacon, Edward de Vere and Christopher Marlowe, among others, are on the rise. (46) An appetite for conspiracy theories, combined with a call for "balance" from some sectors of academe and the rise of the Internet has given the thing new life. Respectable audiences turn up to listen to lectures on it. The controversy is even taught at university level. "What difference does it make who wrote the plays" someone asked the author wearily. Mr. Shapiro (for whom Shakespeare was definitely the man) thinks it matters a lot, and by the end of this book, his readers will think so too.

The authorship controversy turns on two things., snobbery and the assumption that, in a literal way, you are what you write. How could an untutored, untravelled glover’s son from hickville, the argument goes, understand kings and courtiers, affairs of state, philosophy, law, music-let alone the noble art of falconry (47) Worse still, how could the business-minded, property-owning, moneylending materialist that emerges from the documentary scraps, be the same man as the poet of the plays

Mr. Shapiro teases out the cuhural prejudices, the historical blind spots, and above all the anachronism inherent in these questions. No one before the late 18th century had ever asked them, or thought to read the plays or sonnets for biographical insights. No one had even bothered to work out a chronology for them. (48) The idea that works of literature hold personal clues, or that--more grandly--writing is an expression and exploration of the self, is a relatively recent phenomenon.

Contested Will is dense with lives and stories and argument. It is also entertaining. The quest for the true claimant drove people mad. (49) Here are secrets and codes, an elaborate cipher-breaking machine, an obsession with graves and crazy adventures to find lost manuscripts. One man spent months dredging the River Severn. Mr. Shapiro himself turns sleuth, exposing as fraudulent a piece of evidence long thought to be genuine-one more hoax in the long history of Shakespearean wild goose chases.

(50) The Shakespeare that emerges is both simple and mysterious: a man of the theatre, who read, observed, listened and remembered. Beyond that is imagination, In essence, that’s what the book is about.

(50) The Shakespeare that emerges is both simple and mysterious: a man of the theatre, who read, observed, listened and remembered.