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病历摘要王×,25岁,已婚,农民。1988年1月6日因呼吸困唯入院。患者于9个月前妊娠时,出现全身关节疼痛,未治。足月顺产一女婴后病情减轻。入院前6个月时症状再发,并不断发热,咯血,双耳、舌、齿龈、眼眶痛,双下肢皮疹等,之后又出现呼吸困难、声嘶、咯血。拍胸片,诊为“浸润型肺结核”,联合抗痨治疗月余无效。2天前因呼吸困难加重,以上呼吸道不全梗阻收五官科住院。后转内科,诊为结缔组织病?复发性软骨炎?韦格内氏肉芽肿?变应性血管炎。既往史:体健,家中无类似病史,月经正常孕1产1,健在。体检:T39℃,P 120次/分,R40次/分,B P120/60 mmHg,发育正常,神志清,重病容,贫血貌。平卧位,呼吸困难,三凹征阳性,淋巴结不肿大,双下肢散在黄豆粒大小的暗红色斑丘疹,压之不退色,呈盘状凹
Summary of medical records Wang ×, 25 years old, married, farmer. January 6, 1988 due to sleepy only admission. Patients nine months ago during pregnancy, the body joint pain, not cured. Full-term follow-up of a baby girl to reduce the condition. 6 months before admission, the symptoms recurrence and fever, hemoptysis, ears, tongue, gums, orbital pain, rash of both lower limbs, etc., followed by breathing difficulties, hoarseness, hemoptysis. Take chest radiograph, diagnosed as “infiltrative pulmonary tuberculosis”, combined with anti-tuberculosis treatment more than a month is invalid. 2 days ago because of dyspnea aggravating, obstructive respiratory tract upper respiratory tract ENT hospital. After the transfer of medicine, diagnosed as connective tissue disease? Recurrent chondritis? Wegener’s granulomatosis? Allergic vasculitis. Past history: physical health, no similar home history, normal menstruation 1 birth 1, alive. Physical examination: T39 ℃, P 120 beats / min, R40 beats / min, B P120 / 60 mmHg, normal development, clear consciousness, serious illness, anemia appearance. Supine position, difficulty breathing, positive three indentation, lymph nodes are not swollen, the lower limbs scattered in the size of the dark red bean papules, pressure does not fade, was disc-shaped concave