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1992年8月20日查房纪要——主任医师请实习医师报告病历。实习医师患者男性,34岁,农民。因发热、心慌、气促30天,于1992年8月12日入院。患者于30天前,无何诱因,自感周身发热,体温在37～38℃波动,无寒战,无咳嗽、喘息,无腹痛、腹泻,无血尿及膀胱刺激征。伴心慌、气促。自服扑尔敏、感冒片及复方新诺明治疗无明显好转。随到当地医院诊治,听诊心脏有杂音同,诊断为“风湿性心脏病”。
August 20, 1992 rounds minutes - the chief physician asked the intern to report the medical record. Intern Patient Male, 34 years old, farmer. Due to fever, palpitation, shortness of breath 30 days, admitted on August 12, 1992. Patients in the 30 days ago, no incentive, self-perinatal fever, body temperature fluctuations in the 37 ~ 38 ℃, no chills, no cough, wheezing, no abdominal pain, diarrhea, no hematuria and bladder irritation. With palpitation, shortness of breath. Self serving chlorpheniramine, cold tablets and cotrimoxazole treatment no significant improvement. With the local hospital diagnosis and treatment, auscultation of heart auscultation, diagnosed as “rheumatic heart disease.”