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患者李兆英,29岁,农民。主诉:腹巨大及胀痛,呼吸困难,不能平臥已十余天。患者于1961年12月中旬停经,两月后有恶心呕吐及偏食,四月后,自觉胎动,腹渐增大,下肢浮肿,行动不便,尿频尿急,近十天来加剧,以致坐臥不宁,呻吟不绝,不思飲食,于1962年6月15日入院。过去健康,无特殊病史,月经史:17岁初潮,周期为(2—6)/(28—31)日,无经痛史,量中等,色正常。21岁結婚,配偶健在,四胎三产,两男一女,足月分娩,无难产史,儿均健在。检查:发育正常,营养較差,痛苦面容,端坐呼吸,口唇发绀,清醒。下肢有明显可凹性浮肿,体温36.8℃,脉搏98次/分,呼吸30次/分,血压120/80毫米汞柱,体重79公斤,腹围142公分。肺呼吸音粗糙,心律齐,无杂音。腹高度膨隆,腹壁紧张,肝脾未触及,全腹有压痛。
Li Zhaoying patient, 29 years old, farmer. Chief Complaint: huge abdominal and pain, breathing difficulties, can not lie down more than ten days. The patient stopped menopause in mid-December 1961 and had nausea, vomiting and partial ejaculation after two months. After April, he was aware of his fetal movement, his abdomen gradually enlarged, his lower extremity edema, mobility, urinary urgency and exacerbation in the past ten days, Ning, groaning, do not think diet, on June 15, 1962 admission. Past health, no special history, history of menstruation: 17-year-old menarche, the cycle is (2-6) / (28-31) days, no history of menstrual pain, medium, normal color. 21-year-old married, spouse alive, four births, two men and a woman, full-term childbirth, no hardship history, are healthy. Check: normal development, poor nutrition, painful face, sitting and breathing, lips cyanosis, sober. Lower extremity was significantly concave edema, body temperature 36.8 ℃, pulse 98 beats / min, breathing 30 beats / min, blood pressure 120/80 mm Hg, weight 79 kg, abdominal circumference 142 cm. Pulmonary sound of rough breathing, heart rhythm Qi, no noise. Abdominal height bulging, abdominal wall tension, liver and spleen not touched, the whole abdomen with tenderness.