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病历摘要患者男性,28岁,务农,住院号76153。因中上腹反复阵发性剧烈疼痛20余日,于1983年4月5日入院。腹痛时不发烧、无稀便。但伴有恶心,吐酸水。当地医院解痉止痛、补充糖盐水,病情逐日加重。入院体检:体温35.5℃,脉搏细弱130次/分,呼吸30次/分,血压为零。四肢厥冷,神志不清,呼吸有烂苹果味,呈严重脱水状,口唇樱红、皮肤弹性差,瞳孔对光反射迟钝,压眶反射消失。两肺呼吸音粗,心浊音界不扩大,心率130次/分,心音低钝,律齐,无杂音;腹平软,
Patient summary Male patient, 28 years old, farmer, hospital number 76153. Because of the middle and upper abdomen repeated severe pain more than 20 days, on April 5, 1983 admission. Abdominal pain without fever, no loose stools. But accompanied by nausea, spit sour water. Local hospital spasm painkillers, add sugar and salt water, the condition increased day by day. Admission medical examination: body temperature 35.5 ℃, weak pulse 130 beats / min, breathing 30 beats / min, blood pressure is zero. Jueleng limbs, unconsciousness, bad rotten apple breath, severe dehydration, lips Ying Hong, skin elasticity is poor, the pupil light reflex slow, pressure orbital reflex disappears. Breath sound rough two lungs, heart dullness does not expand the heart rate 130 beats / min, heart sound low blunt, law Qi, no noise; abdominal soft,