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患者女性(住院号12013),20岁,未婚,山东蓬莱人。因一周来心悸气短加重,一日来精神失常,于63年2月8日急诊入院。该患者从13岁起即有劳累后心悸气短。并逐加重。曾于60年先后在本院及本市某医院住院四次,均诊断为风湿性心脏病。于入院前一周因不慎受凉后,自觉发烧,全身大关节游走性疼痛,同时心悸气短加重,不能平卧。自服洋地黄片,每天一片共七天。于入院前一天夜间,突然精神失常,兴奋烦躁不安,多语然语无伦次,时而大声哭泣,时而大吵大闹,并有幻听、幻视,如半夜患者不睡,自诉看到大婆在哥哥房内,并听到他们在谈论她的病情。并有离奇之动作,如叫其母将花生米装入其衣袋内,并说:“愈多愈好”;但其母将花生米装入其衣袋后,则患者又自行将花生米掏出。因病情不见好转,故于2月8日下午3时急诊入院。患者自幼性情孤僻、多疑,喜生闷气。五岁时患“麻疹”。经常咽痛。八岁起每于气候变化时有全身大关节游走性疼痛。然从无精神异常史,无头部外伤史,无精神病家族史。体格检查:体温36.8℃,脉搏124/分,呼吸32/分,
Patient Female (hospital number 12013), 20 years old, unmarried, Penglai, Shandong Province. Due to a week palpitations increased shortness of breath, one day mental disorders, in February 8, 63 emergency admission. The patient from the age of 13 after exertion, palpitations shortness of breath. And by weight. Had in 60 years in this hospital and a hospital in the city four times, were diagnosed with rheumatic heart disease. In the week before admission due to accidental cold, consciously fever, systemic painful walking, while palpitations shortness of breath short, can not lie down. Since serving digitalis, a total of seven days a day. On the night before admission, she was suddenly mentally disturbed, excited and irritable, she was in a poor mood, sometimes crying aloud and sometimes loudly and paraphrased. Room, and heard them talking about her condition. And there are bizarre movements, such as call their mother will peanuts into their pocket, and said: “The more you get better”; but the mother of peanuts into their pocket, then the patient and their own out of peanuts . Due to the condition did not improve, so at 3 o’clock on the February 8 emergency admission. Patients since childhood loneliness, suspicious, hi sullen. 5 years old suffering from “measles.” Often sore throat. Since the age of eight, every time when the climate changes, there is systemic pain in the joints. However, no mental abnormal history, no history of head trauma, no family history of mental illness. Physical examination: body temperature 36.8 ℃, pulse 124 / min, breathing 32 / min,