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第一次查房(7月17日) 主治医师:请实习医师报告病历。实习医师:患者,女,26岁。因发冷发热,伴腹痛、关节痛,高热时一过性皮疹,反复发作3个月,于1987年7月12日入院。患者于3个月前因受凉发冷、发热,高热时出现皮疹,伴咽痛,乏力,诊为“上感”。经用大青叶、抗生素治疗,持续半月余体温渐降至正常。2个月前无明显诱因再次发热,伴发冷、腹痛、四肢关节痛,白细胞增高,怀疑“败血症”,给予抗生素及肾上腺皮质激素治疗热退,上述症状缓解。1个月前又发热,仍有腹痛、关节痛,高热时出现皮疹,无痛痒,疑诊“败血症”?“风湿热”?给予抗生素.肾上腺皮质激素及水杨酸钠等药物治疗,病情很快好转而痊愈。1周前为第四次发
The first rounds (July 17) attending physician: Please report the medical record of the intern. Intern: Patient, female, 26 years old. Due to chilly fever, with abdominal pain, joint pain, high fever when a rash, repeated episodes of 3 months, on July 12, 1987 admission. Patients in 3 months ago due to cold and fever, fever, fever, rash, with sore throat, fatigue, diagnosed as “flu”. After using Folium, antibiotic treatment, continued for more than half a month after the body temperature gradually decreased to normal. 2 months ago no obvious incentive to re-fever, with cold, abdominal pain, joint pain, limb leukocytosis, suspected “sepsis”, giving antibiotics and adrenal cortex hormone therapy thermal retreat, the symptoms ease. 1 month ago and fever, there are still abdominal pain, joint pain, high fever when there rash, itching, suspected “sepsis”? “Rheumatic fever”? Given antibiotics .Adrenal cortex hormones and sodium salicylate and other drug treatment, the disease is very Get better and get better soon. 1 week ago for the fourth hair