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病历摘要男性,19岁,农民,住院号298,062。因持续发热、心悸、气促,下肢浮肿2个月,于1982年3月11日入院。患者于2个月前开始发热、咽痛、轻干咳。尿少而黄色,无尿频、尿急,无关节痛。发热10天后出现心悸、气促,晚上不能乎卧,但下肢无浮肿。曾在公社卫生院留医,诊断为风湿性心脏病,用青霉素治疗,效果欠佳。20天后发热仍不能控制,最高达39℃,
Medical record summary Male, 19 years old, farmer, hospital number 298,062. Due to persistent fever, heart palpitations, shortness of breath, edema of the lower limbs for 2 months, was admitted to hospital on March 11, 1982. Patients started fever 2 months ago, sore throat, dry cough. Urinary less yellow, no urinary frequency, urgency, no joint pain. Fever after 10 days palpitations, shortness of breath, can not lie at night, but no swelling of the lower extremities. Had to stay in a commune hospital, diagnosed with rheumatic heart disease, with penicillin treatment, the effect is poor. Fever after 20 days still can not control up to 39 ℃,