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1病例资料患者,男,64岁,2012年4月6日因“头部外伤后头痛伴呕吐20h”入院,否认药物及食物过敏史、癫痫病史。诊断:右颞部硬膜下血肿、右颞叶脑挫伤、右顶骨骨折、外伤性蛛网膜下腔出血。治疗:给予脱水、抗感染、补液等对症支持治疗。4月10日9:30患者一般情况可,精神好转,饮食未进,大小便未见异常。体检:T 36.8℃,R 21次/min,P 86次/min,BP 140/91mmHg;Glasgow评分13分,双侧瞳孔等大等圆,直径约2.5 mm,对光反射存在,口腔无异常分泌物,双肺
1 case data patient, male, 64 years old, April 6, 2012 because of “head trauma with headache and vomiting 20h ” admission, denied drug and food allergy history, history of epilepsy. Diagnosis: Right temporal subdural hematoma, Right temporal lobe brain contusion, Right parietal fracture, Traumatic subarachnoid hemorrhage. Treatment: give dehydration, anti-infection, rehydration and other symptomatic supportive treatment. At 9:30 on April 10 the general condition of patients can be, the spirit improves, the diet has not yet entered, the urine was normal. Physical examination: T 36.8 ℃, R 21 times / min, P 86 times / min, BP 140/91 mmHg; Glasgow score 13 points, bilateral pupil and other large round, diameter of about 2.5 mm, the presence of light reflex, no abnormal oral secretion Things, both lungs