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病历摘要女性,17岁。1980年12月住院。因发烧伴有心悸、四肢酸痛、微咳,无关节红肿及游走性痛,亦无胸痛与盗汗,1周后住某院。当时体征:血压92/62mmHg,无发绀,皮肤无结节及红斑。咽充血。无颈静脉怒张。肺无异常。心前区无震颤,心界稍大,心率88次/分,律齐,P_2>A_2,胸骨左缘第3肋间收缩期及舒张早中期吹风性杂音。肝脾未扪及,无腹水征及浮肿。
Summary of medical records Female, 17 years old. 1980 December hospitalization. Because of fever with palpitations, limb pain, cough, no joint swelling and migratory pain, no chest pain and night sweats, a week after living in a hospital. At that time signs: blood pressure 92 / 62mmHg, no cyanosis, skin nodules and erythema. Pharyngeal congestion. No jugular vein engorgement. No abnormal lungs. Heart area before no tremor, heart slightly larger, heart rate 88 beats / min, law Qi, P_2> A_2, sternal left intercostal intercostal space and diastolic early and middle hair blowing noise. No palpable liver and spleen, no signs of ascites and edema.