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1病历报告患者,男,20岁。2010年10月31日因胸、腹、左大腿部刀伤2h余来诊,曾去当地县医院,给予输升压、补液药物治疗及伤处包扎后来诊。就诊时查体:T36.9℃,P110次/min,R21次/min,BP100/50mmHg,嗜睡,面色、眼睑、四肢色苍白,双侧瞳孔正大等圆,对光反射灵敏,颈对称无畸形,双侧颈静脉无怒张,无颈动脉异常搏动,颈无抵抗,胸廓对称
1 medical record patient, male, 20 years old. October 31, 2010 due to chest, abdomen, left thigh wounds 2h Yu came to the clinic, went to the local county hospital, giving loser pressure, rehydration drug treatment and wound dressing visit. Examination at the time of examination: T36.9 ℃, P110 times / min, R21 times / min, BP100 / 50mmHg, drowsiness, complexion, eyelids, pale limbs, bilateral pupil Zhengda and other round, sensitive to light reflection, neck symmetry without deformity , Bilateral jugular vein without anger, no abnormal beating of carotid artery, neck without resistance, thorax symmetry