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患者,女,18岁。2014年5月13日因“敏感多疑,凭空闻语一年余”入院。既往无抗精神病药用药史及药物过敏史。平时月经规律,末次月经2014年5月1日。入院体检:T36.5℃,P 80次/min,R 20次/min,BP 110/70 mmHg。心肺腹检查未见明显异常。精神检查:意识清楚,言语清晰,语速适中,仪表整洁,接触被动合作,注意力欠集中,记忆力、智能、计算力正常。情绪低落,烦躁,评论性幻听,关系妄想,被害妄想,内心被洞悉感,意志行为减退,自知力缺如。入院后完善
Patient, female, 18 years old. May 13, 2014 due to “sensitive and suspicious, heard more than a year ” admission. Past antipsychotic medication history and drug allergy history. The usual menstrual regularity, the last menstrual May 1, 2014. Admission examination: T36.5 ℃, P 80 beats / min, R 20 beats / min, BP 110/70 mmHg. Cardiopulmonary abdominal examination showed no obvious abnormalities. Mental examination: Consciousness, clear language, moderate speech speed, instrument clean, contact passive cooperation, attention deficit concentration, memory, intelligence, calculation power is normal. Depression, irritability, auditory hallucinations, delusional relationship, victimized delusions, inner sense of insight, diminished will behavior, lack of insight. After admission, perfect