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病历摘要赵××,女,36岁,家庭妇女。因突然失语,右侧肢体不能活动2天,于1962年12月16日入院。患者于入院前1日下午5时活动中突然口角右歪,不能讲话,右侧肢体不能活动。1个半小时后稍有缓解,能讲简单的话,但声音不清晰。发病前感心慌、气短、无头痛、头晕、恶心及呕吐,也无意识障碍、抽搐及尿便失禁。16岁时患风湿性关节炎,33岁时患风湿性心脏病,曾有心力衰竭3次。平时服毛地黄维持量治疗,可以从事轻家务劳动,但经常觉心悸、气短。妊娠5次,分娩2次,2个孩子健在。爱人患精神病。检查:血压130/80毫米汞柱,呼吸18次/分,脉搏140次/分。发育中等,营养稍差,可以平卧,慢性病容,无紫绀,皮肤无黄染。表浅淋巴结不大,五官正常,气管居中,
Medical record summary Zhao × ×, female, 36 years old, domestic women. Due to sudden aphasia, the right limb can not be active for 2 days, was admitted on December 16, 1962. Patients in the activity on the 1st before admission at 5 o’clock in the event of a sudden right angle crooked, unable to speak, the right limb can not move. After a half an hour a little ease, can speak simple, but the sound is not clear. Pre-onset flu, shortness of breath, no headache, dizziness, nausea and vomiting, unconsciousness, convulsions and urinary incontinence. 16-year-old suffering from rheumatoid arthritis, 33-year-old suffering from rheumatic heart disease, had heart failure 3 times. Usually take clothes to maintain the amount of treatment, you can do light housework, but often feel palpitations, shortness of breath. Pregnancy 5 times, childbirth 2 times, 2 children alive. Love people suffering from mental illness. Check: blood pressure 130/80 mm Hg, breathing 18 beats / min, pulse 140 beats / min. Moderately developed, slightly less nutritious, supine, chronic disease, no cyanosis, no yellow skin. Small superficial lymph nodes, facial features normal, tracheal center,