论文部分内容阅读
病历摘要忠者女性,25岁,工人。双下肢浮肿, 两踝关节疼痛逐渐加重1月余,于81年12月入院.病程中伴有乏力,尿急,肝功轻度异常,血压浮动在160～180/90～110mmHg。既往有慢性扁桃体炎,已手术;牙龈经常出血10个月;全身表浅淋巴结肿大10年余,活(?)示慢性炎症。诊断①慢性活动性肝炎②结节性动脉周围炎。入院时查体:一般情况好,体温37℃.血压190/110mmHg,头发稀疏,颜面、腕、膝关节轻度至中度浮肿,踝关节及足背处凹陷性水肿。巩膜无黄染。未见皮下瘀血及出血点,无蜘蛛痣及肝掌。颌下、腕下、腹股沟均可触及黄豆及花生米大小的活动无触痛之淋巴结。心肺听诊正常。腹软,肝脾未及,腹水征(-),脊柱及四肢无畸形,神经系统检查正常。
Summary of medical records Female loyal, 25 years old, worker. Lower extremity edema, two ankle joint pain gradually increased more than 1 month, admitted in December 81. Course of the disease associated with fatigue, urinary urgency, mild liver abnormalities, blood pressure fluctuations in the 160 ~ 180/90 ~ 110mmHg. Past chronic tonsillitis, surgery; gum bleeding often 10 months; systemic superficial lymph nodes more than 10 years, live (?) Chronic inflammation. Diagnosis ① chronic active hepatitis ② nodular periarteritis. Physical examination on admission: generally good, body temperature 37 ° C. Blood pressure 190 / 110mmHg, thinning hair, face, wrist, knee mild to moderate edema, ankle and dorsal foot depression edema. Sclera without yellow dye. No subcutaneous bleeding and bleeding, no spider nevus and liver palms. Submandibular, wrist, groin can reach the size of soybean and peanut-free activity of tender lymph nodes. Cardiopulmonary auscultation normal. Abdominal soft, liver and spleen is not, signs of ascites (-), spine and limbs without deformity, normal nervous system examination.