Briefing of patients’ condition: Yesterday, the patient suffered from paroxysmal abdominal colic without radiating pain, suffered from watery stool six times with nausea, suffered from vomiting between six to eight times, which is watery content and gastric content, without haematemesis and tarry stool. The patient felt dizzy and languid. The patient didn’t have headache, sweating and fever symptoms. The patient had a normal urinating without chest distress and palpitation. The patient didn’t have tic, unconsciousness and gatism symptoms. Physical examination: T: 37.1℃ P: 80 times per min R: 20 times per min BP: 130/70mmHg. The patient is conscious, not looking dehydrated, with soft abdomen and pressing pain on the middle of belly button and without rebound tenderness. His bowel sound is slightly hyper-functional at between seven to eight times per min. Blood routine: WBC 17.8x109/L N 83.9%. Stool routine: WBC: 8-10/HPF Without mucus and pus and blood.

Admitting diagnosis:

1. Chronic superficial gastritis.

Treatment suggestions:

1. Spasmolysis, symptomatic, anti-infection and fluid infusion treatment;

2. Nurse one’s health by taking traditional Chinese medicine and cycle therapy;

3. Quiet rest, pay attention to diet and see a doctor when feeling uncomfortable.

The Third People’s Hospital of xxxxx City

Dedicated stamp for disease diagnosis

Digestive system department physician (signature of medical certificate)

Xxxxxxx

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