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1病历摘要女,40岁。因反复头晕1周,于2011-07-29入院,查体:T36.4℃,HR 90次/min,R 20次/min,BP 100/80mm Hg,头部昏沉,伴视物旋转、气短乏力,心烦焦虑、口干苦,夜寐多梦、不安。既往史:1a前无明显诱因出现月经量不规律,主要表现为量少、色暗、腹痛、腰酸乏力,带经时间短,完善相关检查未见明显异常,间断服用中药治疗,疗效不佳;对青霉素过敏。诊断
1 medical record summary female, 40 years old. Due to repeated dizziness for 1 week, admitted on July 29, 2011, physical examination: T36.4 ℃, HR 90 beats / min, R 20 beats / min, BP 100 / 80mm Hg, head drowsiness, accompanied by object rotation, shortness of breath Fatigue, upset anxiety, dry mouth, night sleep soundly, restless. Past history: there is no obvious incentive before menstruation irregular menstruation, mainly for the less, dark color, abdominal pain, backache fatigue, with a short period of time, improve the relevant inspection no obvious abnormalities, discontinuous use of traditional Chinese medicine treatment, curative effect is poor; Allergic to penicillin. diagnosis