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病史摘要患者女,20岁,未婚,住院号133131。入院日期1975年4月18日13时,死亡日期1975年4月26日4时42分。患者于1975年3月14日因两下肢浮肿、乏力、腰酸、尿频、尿痛、尿蛋白++++而收入某院住院治疗。入院检查:血压94/70毫米汞柱,扁桃体轻度肿大,心肺正常,肝脾未及,四肢无浮肿.24小时尿蛋白定量6.5克,多次尿液检查蛋白+～++++,有管型及红、白细胞(转院病历未记量),尿培养(-),非蛋白氮26毫克%,肌酐1.25毫克%,胆固醇429毫克%。诊断为慢性肾炎,肾病综合征,曾给予青霉素及中草药治疗。4月14日中午患者因吃有“小虫”飞入过的猪肉汤,并将剩汤晚上再喝,当晚呕吐4次,血压90/70毫米汞柱。4月15日上午7时30分仍呕吐伴头痛,大便一次,成形,血压降至40/O毫米汞柱,心率118次/分,律齐,肺(-),曾给予氢化考的松100毫克,氯霉素1克及新福林、阿拉明、多巴胺各1支静滴。上午10时血压120/70毫米汞柱,但未停升压药。下午7时45分血压190/120。患者烦躁,剧烈头痛,停用升压药。下午8时10分突然两眼上翻,全身强直性阵挛性抽搐,历时一分钟而止,抽搐时心跳存在。导尿尿量250毫升,灌肠大便镜检:粘液+++,红细胞9～10个/高倍视野,白细胞+。15日～18日间每天大便3～4次,有里急后重感,量少,粘液带胶冻样。4月16日:排尿500毫升,血尿一次,30毫升。给氯霉素2克,青霉素200万单位静滴,并口服链霉素。4月17日:咳出粉红色泡沫痰,心率120次/分,两肺满布干湿罗音,床边摄片
Summary of medical history Female patient, 20 years old, single, hospital number 133131. Date of admission At 13 a.m. on April 18, 1975, the date of death was April 4, 1975, at 4:42 pm. Patients on March 14, 1975 due to edema, fatigue, backache, frequent urination, dysuria, urinary protein ++++ income hospital treatment. Admission examination: blood pressure 94/70 mm Hg, tonsil mild enlargement, normal heart and lung, liver and spleen and edema, extremities without edema .24 urinary protein quantitation of 6.5 grams, multiple urinalysis protein + ~ ++++, Tubular and red, white blood cells (transfusion records were not recorded), urine culture (-), non-protein nitrogen 26 mg%, creatinine 1.25 mg%, cholesterol 429 mg%. Diagnosis of chronic nephritis, nephrotic syndrome, penicillin and Chinese herbal medicine have been given treatment. At noon on April 14, the patient swallowed the pork soup that had been eaten by the “bug,” and left the soup overnight to drink. He vomited four times that night with a blood pressure of 90/70 mm Hg. At 15:30 on April 15 still vomiting with headache, stool, forming, blood pressure dropped to 40 / O mm Hg, heart rate 118 beats / min, law Qi, lung (-), had given hydrocortisone 100 Mg, 1 g of chloramphenicol and a new infusion, alamin, dopamine, a intravenous infusion. The blood pressure was 120/70 mm Hg at 10 a.m. but the pressure was not stopped. The blood pressure was 190/120 at 7.15 p.m. Patients with irritability, severe headache, disable antihypertensive drugs. At 8:10 pm a sudden turn around his eyes, the whole body tonic clonic convulsions, which lasted a minute, the heartbeat of convulsions exist. Guided urine output 250 ml, enema stool microscopy: mucus +++, 9 to 10 red blood cells / high power field, white blood cells +. 15 days to 18 days a day stool 3 to 4 times, after a tenesmus, less, mucus with jelly-like. April 16: Urination 500 ml, hematuria once, 30 ml. To 2 grams of chloramphenicol, penicillin 2 million units intravenous infusion, and oral streptomycin. April 17: cough pink sputum sputum, heart rate 120 beats / min, both lungs covered with wet and dry rales, bedside radiography