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患者肖××(住院号6445),女性,32岁,家庭妇女,承德市人,于1963午5月26日因上腹痛、恶心呕吐4小时急诊入院。患者于妊娠二月余,服斑蟊1钱5分,以图堕胎,服后10分钟,即感恶心、呕吐频繁,吐物为血性液体,口腔、咽喉及上腹部有烧灼感,伴有疼痛,4小时后来院急诊。入院时体检:体温38℃,脉搏108次/分,呼吸18次/分,血压98/50毫米汞柱。发育正常,营养中等,神智清醒合作,急性痛苦病容,皮肤无水疱及出血点,呈轻度脱水状。口腔粘膜、咽及软颚有散在性水疱及糜烂面,有血性渗出物。颈部、心、肺正常,腹平软,上腹部明显压痛,四肢脊柱正常,阴道见少许血液。生理反射存在,无病理反射。化验室检查:红细胞525万/立方毫米,血红蛋白13.5克,白细胞21200/立方毫米,中性细胞90%,淋巴细胞10%。尿化验:蛋白(+),镜检脓球(++)、红细胞(?)。血非蛋白氮28.5毫克%,二氧化碳结
Patient Xiao XX (hospital number 6445), female, 32 years old, domestic woman, Chengde City, on May 26, 1963 due to upper abdominal pain, nausea and vomiting 4 hours emergency admission. Patient in February of February of pregnancy, serving spot catfish 1 money 5 points, in order to abortion, after serving 10 minutes, that is, nausea, vomiting, vomiting bloody fluid, mouth, throat and upper abdomen with burning sensation, accompanied by pain, 4 hours later to hospital emergency room. Physical examination on admission: body temperature 38 ℃, pulse 108 beats / min, breathing 18 beats / min, blood pressure 98/50 mm Hg. Normal development, moderate nutrition, sober cooperation, acute pain, skin blisters and bleeding points, showed mild dehydration. Oral mucosa, pharynx and soft jaw have scattered blisters and erosion surface, bloody exudate. Neck, heart, lungs normal, abdominal soft, obvious tenderness on the abdomen, spine limbs normal, see the vagina a little blood. Physiological reflex exists, no pathological reflex. Laboratory tests: 525 million / cubic mm of erythrocytes, 13.5 grams of hemoglobin, 21200 / cubic mm of white blood cells, 90% of neutral cells, 10% of lymphocytes. Urinalysis: protein (+), microscopy pus (++), red blood cells (?). Non-protein nitrogen 28.5 mg%, carbon dioxide