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病历摘要李××,男,63岁,退休工人,因突然昏迷10小时于1976年11月10日17时15分急诊入院。患者11月9日晚睡前尚好,次日晨8时家人呼叫时始发现患者已昏迷,未见呕吐,抽搐,大小便失禁及发热。当时血压200/110。1972年12月因高血压动脉硬化蛛网膜下腔出血曾在本科住院。患癲痫,慢性支气管炎合并肺气肿多年,常服大仑丁、鲁米那和降压灵等药。体格检查:体温37℃,脉搏102次,血压134/80,呼吸较深大,并闻可疑漂白粉气味,指、趾轻度发绀。头颅和五官无畸形,皮肤和巩膜无黄染与出血点,表浅淋巴结未扪及。颈软,气管居中,甲状腺不肿大。桶状胸,双肺可闻痰鸣音,心律整,各瓣膜区未闻病理性杂音。腹软,肝、脾未触及,四肢无浮肿。深昏迷,双瞳孔对称性缩小,直径1毫米,对光反射极弱,眼底窥不清,眼脑反射和脊睫反射消失,压迫眶上切迹及捻捏肢体无反应,四肢肌张力低,腱反射对称性减弱,未引出病理反射。实验室检查血:白细胞13,600、杆状5%、分叶83%、淋巴
Medical record summary Li × ×, male, 63 years old, retired workers, due to a sudden coma 10 hours on November 10, 1976 at 17:15 emergency admission. The patient was asleep before going to bed on the evening of November 9, and when the family called at 8 am the next morning, the patient was found unconscious, vomiting, convulsions, incontinence and fever. At that time blood pressure 200/110. December 1972 due to hypertensive arteriosclerosis subarachnoid hemorrhage was hospitalized. Suffering from epilepsy, chronic bronchitis with emphysema for many years, often serving Daren D, Lumi Na and antihypertensive drugs. Physical examination: Body temperature 37 ℃, pulse 102 times, blood pressure 134/80, deeper breathing, and smell the smell of suspicious bleach, finger, mild cyanosis of the toes. Head and facial features without deformity, skin and sclera without yellow dye and bleeding points, superficial lymph nodes not palpable. Neck soft, tracheal center, thyroid does not enlarge. Barreled chest, lungs can be heard phlegm, heart rhythm, the valve area is not heard pathological murmur. Abdominal soft, liver, spleen not touched, no swelling of limbs. Deep coma, double pupil symmetry reduced diameter of 1 mm, the light reflex is very weak, peephole unclear, reflex eye and reflex, the compression of the supraorbital notch and twist pinch limb no reaction, limb muscle tension is low, The symmetry of tendon reflex decreased, did not lead to pathological reflex. Laboratory tests Blood: 13,600 leukocytes, 5% rod, 83% leaf, lymph