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病历摘要肖×,男性,17岁,农民,住院号68461。因头晕、眼花、齿龈出血5天于1961年5月26日入院。患者于入院前半个月劳动时被瓦片割破左足(?)趾,局部渗血,6天始止,伤口并无红肿。此后渐觉头晕、眼花、齿龈渗血,症状日渐加剧,以至不能起床。病后自觉无寒战、发热,但面色日渐苍白,胃纳不振,消瘦。除外敷过中草药外,未用过任何药物治疗。既往无接触化学毒物史,亦无出血倾向的个人史或家族史。
Medical record Xiao X, male, 17 years old, farmer, hospital number 68461. Due to dizziness, vertigo, bleeding gums 5 days in May 26, 1961 admission. The patient was cut by the tile with a left foot (?) Toe while working for the first half of the hospital stay. Local bleeding was observed. The wound was not swollen at 6 days. Since then gradually dizziness, vertigo, gum bleeding, the symptoms intensified, and even can not get up. After the disease consciously no chills, fever, but looking increasingly pale, poor appetite, weight loss. Except for herbal medicine, no medication has been used. No previous exposure to chemical poisons, no personal or family history of bleeding tendency.