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病历摘要 患者,李某某,男,19岁,工人,因发热消瘦40余天于1987年9月12日入院,起病前无明显诱因突感畏寒,发热、寒颤、右膝关节及全身疼痛,局部无红肿,活动稍受限。在外院诊断为风湿性关节炎,给予青霉素、萘普生治疗,疼痛减轻,仍发热、多汗、食欲减退、消瘦明显,体重下降5kg。无咳嗽、咯血、皮肤或牙龈出血,无腹痛。大小便正常。 体检 T39.7℃,P120次,R20次,BP14.6/9.3kPa(110/70)。慢性病容,消瘦,轻度贫血貌,巩膜无黄染。皮肤、粘膜无出血点。颈部、腋窝、腹股沟可扪及直径0.2～0.5cm大小淋巴结,质地中等,无压痛。咽部稍充血,扁桃体不肿大。颈部阻力可疑,胸骨无压痛。心肺无异常,心率120次。
Patient, Lee Moumou, male, 19 years old, worker, admitted to hospital on September 12, 1987 due to fever and weight loss more than 40 days, no obvious incentive before the onset of sudden chills, fever, chills, right knee and general pain , No local swelling, slightly limited activity. In the outpatient diagnosis of rheumatoid arthritis, given penicillin, naproxen treatment, pain relief, still fever, sweating, loss of appetite, weight loss significantly, weight loss 5kg. No cough, hemoptysis, skin or bleeding gums, no abdominal pain. Normal urine. Physical examination T39.7 ℃, P120 times, R20 times, BP14.6 / 9.3kPa (110/70). Chronic disease, weight loss, mild anemia, sclera no yellow dye. Skin, mucous membrane without bleeding point. Neck, armpit, groin palpable and 0.2 ~ 0.5cm in diameter lymph nodes, medium texture, no tenderness. A little throat congestion, tonsil does not enlarge. Suspected neck resistance, no tenderness in the sternum. No abnormal heart and lung, heart rate 120 times.