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患者女性,38岁,住院号12508,于1957年8月29日因抽搐及神志昏迷10天入院。据其爱人称患者于10天前因与人争吵过一次,开始发病,最先感到两腿麻木无力,有时两下肢阵发性抽搐,伴有呕吐,每日三、四次,吐出为水样物,以后就不说话而发生昏迷,曾经当地卫生院诊治无效,遂急诊来院求治。过去史:自去年4月份起,经常手脚发麻,与家人争吵后即发生昏迷不说话,经当地医生诊治而好转。月经及分娩史:16岁月经初潮,周期约30日左右,持续5—6日,18岁结婚,生产九胎(死去三胎,健存六胎),去年4月份足月平产第九胎,产后阴道大量流血,当时并未发生昏厥、产后乳汁迄今末分泌,自该次生育后,月经停止,未再怀孕,以后身体日渐虚弱,经常昏厥不说话,便秘,对性生活兴趣减低,同时腋毛、阴毛渐渐脱落。体格检查:体温36.5℃,脉搏70次/分,呼吸18次/分,血压96—100/68—70毫米汞柱。颜貌愚笨,乏表情,面色苍
Patient Female, 38 years old, hospital number 12508, admitted to hospital on convulsions and delirium for 10 days on August 29, 1957. According to their lover said the patient 10 days ago due to quarrel with people once, began to attack, first feel the legs numbness, and sometimes both lower limbs paroxysmal convulsions, accompanied by vomiting, three or four times a day, spit out as a water sample Things, the future did not speak and coma, once the local clinic invalid treatment, then emergency treatment to the hospital. Past history: since April last year, often numb hands, quarrel with his family immediately after a coma do not speak, the local doctor for treatment and improvement. Menstruation and childbirth history: 16 years of menarche, the cycle of about 30 days, lasting 5-6, 18-year-old married, the production of nine tires (died of three births, six healthy births), in April last year, , A large number of postpartum vaginal bleeding, did not occur fainting, postpartum milk secretion so far, since the birth, menstruation stopped, no longer pregnant, after the body became weaker, often fainting do not speak, constipation, reduced interest in sexual life, at the same time Armpit hair, pubic hair gradually fall off. Physical examination: body temperature 36.5 ℃, pulse 70 beats / min, breathing 18 beats / min, blood pressure 96-100 / 68-70 mmHg. Color stupid, lack of expression, pale face