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病历摘要患者女,56岁。于1982年4月4日入院。19年来渐进性怕冷、乏力、活动减少,喜于坐卧取暖。食欲不振,经常便秘,全身浮肿及声音嘶哑等。一直按慢性肾炎治疗未能奏效。近2月来终日卧床,淡漠嗜睡,5日来意识模糊,口唇发绀。既往身健,家族中无特殊病史。体格检查:体温34℃(肛表),脉搏52次,呼吸2次,血压86/50。轻度昏迷,口唇和指甲明显紫绀。皮肤干糙,中度非凹陷性浮肿。体表浅淋巴结不肿大。头发桔黄。双侧瞳孔等大,直径4mm,对光反应迟钝。
Patient history Female, 56 years old. On April 4, 1982 admission. 19 years of progressive cold, fatigue, activities to reduce, hi sit warm. Loss of appetite, frequent constipation, generalized edema and hoarseness. Has been treated by chronic nephritis failed to work. Nearly two months to bed all day, indifference to lethargy, the 5th day to the confusion, lips cyanosis. Past health, no special family history. Physical examination: body temperature 34 ℃ (anal surface), pulse 52 times, breathing 2 times, blood pressure 86/50. Mild coma, obvious cyanosis of lips and nails. Dry skin, moderate non-pitting edema. Superficial lymph nodes are not swollen. Hair orange. Pupil and other large bilateral, diameter 4mm, unresponsive to light.