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病历摘要 [例一]李某,女13岁,职工子女。于1973年9月21日17时10分急诊入院,23日10时20分死亡。代主诉:误食毒蕈五天,黄疸三天,昏迷一天。病史:患儿全家于9月16日晚饭共食鲜蕈约1市斤半。因患儿吃饭最慢,把剩余的蕈菜和汤全部吃完。当晚深夜二时许(即17日晨),患儿因呕吐腹泻多次被送往厂卫生所留治,经注射阿托品等,症状好转后于下午步行回家。但患儿病情逐渐加重,19日出现巩膜、皮肤黄染;20日下午神志模糊;21日昏迷状态并抽搐多次。体检:昏迷状态,体温(腋)38.8℃;血压116/60毫米Hg,脉搏156次/分,呼吸均匀,有肝臭。皮肤、巩膜黄染但无出血
Medical record summary [Example 1] Lee, 13-year-old female, workers and children. At 21:17 on September 21, 1973 emergency admission, at 10:20 on the 23rd died. Chief complaint: Eat poison mushroom five days, jaundice three days, coma one day. History: Children with children on September 16 dinner a total of about one kilogram of fresh mushrooms and a half kilograms. Because children eat the slowest, the remaining mushrooms and soup all finished. Two o’clock that night late night (ie, 17 morning), children with vomiting and diarrhea repeatedly sent to the factory clinic, after the injection of atropine, symptoms improved after walking in the afternoon walk home. However, the patient’s condition gradually aggravate, sclera 19, skin yellow dye; the afternoon of 20 ambiguous; 21 coma and convulsions many times. Physical examination: coma, body temperature (axillary) 38.8 ℃; blood pressure 116/60 mm Hg, pulse 156 beats / min, breathing evenly, with liver odor. Skin, scleral yellow dye but no bleeding