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病历摘要女,33岁,河北正定农民。患者于1977年9月开始出现对外周刺激无反应,表情呆滞,默默不语,拒食,类木僵及违拗状态,自知力丧失。在某精神病院住院,诊断为精神分裂症紧张型,内服冬眠灵、奋乃静三个月,症状加重,脱发,发作性心慌,出汗,昏厥。以“待查”于1977年11月15日转入内科。体检:体温不升,血压86/60mmHg。皮肤苍白干涩,乳房萎缩,乳晕色浅,腋毛阴毛脱落;非指凹性水肿,四肢厥冷;心脏左侧扩大,心音弱,律齐,无杂音;肝脾不大;神志呆滞,表情淡漠,回答问题缓慢、欠准确,自知力模糊;神经系统未见异常。追问病史,1969年第三胎产后大出血,昏迷,未输血输液。产后20天无乳,畏寒。三个月后,腋毛阴毛脱落,头晕眼花,乏力消瘦。近三个月来脱发,性欲消失,精神失常。
Female medical record, 33 years old, Hebei Zhengding farmers. Patients began to appear in September 1977 no response to peripheral stimulation, sluggish, silent, antifeedant, stupor and disobedient state, loss of self-knowledge. Hospitalized in a mental hospital, diagnosed as schizophreniform tension, oral winter sleep Ling, perphenazine for three months, the symptoms increase, hair loss, paroxysmal palpitation, sweating, fainting. To “pending” on November 15, 1977 into the internal medicine. Physical examination: body temperature does not rise, blood pressure 86 / 60mmHg. Skin pale and dry, breast atrophy, areola color shallow, armpit hair pubic hair off; non-finger concave edema, extremities Jueleng; heart left to expand, weak heart, law Qi, no noise; small liver and spleen; Answer the question is slow, not accurate, ignorant; nervous system no abnormalities. Asked history, the third child postpartum hemorrhage in 1969, coma, no blood transfusions. 20 days postpartum without milk, chills. Three months later, armpit hair pubic hair loss, dizziness, fatigue and weight loss. Almost three months to hair loss, loss of libido, mental disorders.