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患者男,66岁,农民,13 h 前在家往墙里钉铁钉时自诉头晕,遂被扶下休息,出现昏迷,无抽搐,无恶心呕吐。近3 d诉头额闷痛,1周前有呼吸道感染史。嗜烟酒40余年,有无高血压病史不详。在当地医生测血压为100/70 mmHg。给予抗感染对症处理,神志无变化。于夜间由“120”接入我科。入院时查体:体温38.2℃,心率100次/min,呼吸25次/min,血压105/70 mmHg。浅昏迷状态,呼之不应,被动仰卧位,双瞳光反射灵敏,口唇不发绀,咽不充血。颈项有抵抗感,甲状腺不肿大,颈静脉不怒张。桶状胸,叩诊呈过清音,双肺未闻及干、湿罗音。心界向左下移,心率100次/min。
Male, 66, a peasant, complained of dizziness when nailing a nail to a wall at home 13 hours ago. He was then instructed to rest, have a coma, have no convulsions, and have no nausea and vomiting. Nearly 3 d vomit head pain, 1 week ago, a history of respiratory tract infection. Alcohol and tobacco more than 40 years, with or without a history of hypertension is unknown. The local doctor measured blood pressure 100/70 mmHg. Give anti-infection symptomatic treatment, no change in consciousness. In the night by the “120 ” access to our department. Admission examination: body temperature 38.2 ℃, heart rate 100 beats / min, breathing 25 times / min, blood pressure 105/70 mmHg. Shallow unconscious state, call should not, passive supine position, double pupil light reflection sensitive, lips are not cyanotic, pharynx is not congestive. Neck resistance, thyroid enlargement, jugular vein does not anger. Barreled chest, percussion was voiceless, lungs did not smell and dry, wet rales. Heart left down, heart rate 100 times / min.