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病历摘要患者刘某,(住院号97130,尸检号59097)女性,25岁,已婚,草绳工人,吉林省人,因头痛2个月,全身浮肿一个月于1959年10月10日入院。于2个月前开始间歇性头痛,服止痛药片尚能坚持工作。一个月来头痛呈持续性,服药无效,并伴发浮肿,由面部开始渐波及全身,且出现低热,尿量减少。于当地就医检查发现血压260/180毫米汞柱,诊断为“慢性肾炎”及“高血压”。随后渐次出现心跳,气短,两眼视物模糊。病程中无恶心、呕吐,食欲尚好。既往史:12岁时患“血尿”,并有由面部开始的全身浮肿,并有头痛,头晕,经治疗一年半后而癒。18岁患“腰椎结核”,经中医治疗三年而癒。无咽痛史。结婚两次未生育,月经16岁初潮,仅来两次,以后闭经至21岁,又恢复正常。爱人有性病史。家族中无高血压病人,其母有结核病。
Patient, aged 25, married, carapace worker, Jilin province, was admitted to hospital on October 10, 1959 due to a headache for 2 months. Intermittent headache started 2 months ago, still can keep painkiller tablets work. Headache continued for a month, taking medication ineffective, accompanied by edema, gradually began to spread from the face and body, and fever, decreased urine output. Local medical examination found that blood pressure 260/180 mm Hg, diagnosed as “chronic nephritis” and “high blood pressure.” Then gradually appear heartbeat, shortness of breath, blurred vision of both eyes. Nausea during the course of disease, vomiting, appetite is still good. Past history: 12 years old suffering from “hematuria,” and the whole body from the face edema, and headaches, dizziness, and more after a year and a half after treatment. 18-year-old suffering from “lumbar tuberculosis,” three years of Chinese medicine and more. No sore throat history. Married twice without childbearing, menstruation 16-year-old menarche, only two times, after amenorrhea to 21 years old, returned to normal. Loving sex history. No hypertension in the family, the mother has tuberculosis.