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病历摘要钟某,男,28岁,因“额部外伤13天,头痛,呕吐9天”于1986年5月15日入院。患者于5月3日被一1cm大小飞石击中额部致皮肤裂伤,流血少许,无其他不适。伤后3天出现头痛、呕吐,呕吐物为食物、蛔虫及少许血液,在当地医院给予青霉素、庆大霉素、驱虫等治疗无好转,并出现全身疲乏、酸痛、肢端麻木,遂来我院门诊内科以“轻型脑外伤”收住院。既往史无特殊。查体:T37℃,P90次/分,R22次/分,BP13.3/9.33kPa,急性痛苦病容,神清合作,自动体位,全身皮肤有散在瘀斑,浅表淋巴结不肿大,在额部近眉弓处有1cm长疤痕,矾膜无出血及黄染,双侧瞳孔等大,直径0.25cm,对光反射正常。砰在肋下1.5cm,剑突下3cm,余无异常。实验室检查:白细胞总数5.7×10~9～18.9
Medical summary Zhongmou, male, 28 years old, was admitted to the hospital on May 15, 1986 because of “forehead trauma for 13 days, headache and vomiting for 9 days.” Patients on May 3 by a 1cm size flying stone hit the forehead caused by skin laceration, bleeding a little, no other discomfort. 3 days after injury headache, vomiting, vomit food, roundworms and a little blood, given in the local hospital penicillin, gentamicin, deworming and other treatment without improvement, and the body fatigue, soreness, limb numbness, then come Outpatient clinic in our hospital to “light brain injury” admitted to hospital. No previous history. Physical examination: T37 ℃, P90 beats / min, R22 beats / min, BP13.3 / 9.33kPa, acute pain and sickness, Shen Qing cooperation, automatic position, systemic ecchymosis, superficial lymph nodes not enlarged, Department near the eyebrow 1cm long scar, alum film without bleeding and yellow dye, bilateral pupils and other large, diameter 0.25cm, the normal light reflex. Bang 1.5cm under the ribs, xiphoid 3cm, I no exception. Laboratory tests: the total number of leukocytes 5.7 × 10 ~ 9 ~ 18.9