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第一次查房(7月21日) 主任医师:请实习医师报告病历摘要。实习医师:患者,男,13岁。因溺水伴昏迷2小时于1985年7月20日急症入院。患者于2小时前在池溏洗澡,不慎溺水。被人打捞后面色口唇青紫,呼吸微弱、昏迷。当场进行人工呼吸,呼吸好转后而急转我院。查体:T35.5℃/,P160次/分,R30次/分,BP14.63/10.64 kPa(110/80mmHg)。浅昏迷状态。全身皮肤粘膜轻度紫绀,呼吸表浅节律不整。双瞳孔中度散大光反射迟钝,颈软,心
The first rounds (July 21) chief physician: ask an intern to report a medical summary. Intern: Patient, male, 13 years old. Due to drowning with coma 2 hours on July 20, 1985 emergency admission. Patients bath in the pond 2 hours ago, accidentally drowned. Was salvaged after the color blue lips, weak breathing, coma. Artificial resuscitation on the spot, breathing improved and immediately after the hospital. Physical examination: T35.5 ℃ /, P160 beats / min, R30 beats / min, BP14.63 / 10.64 kPa (110 / 80mmHg). Shallow unconscious state. Systemic skin and mucous membrane mild cyanosis, breathing shallow irregular rhythm. Double pupil moderate light reflex slow, soft neck, heart