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第一次查房住院医师:请进修医师报告病历摘要。进修医师:患者,男,35岁。8个月前开始出现多尿、烦渴、多饮、善饥多食,疲乏、消瘦。双手指关节疼痛。无腹痛、腹泻。近3月来出现周期性发热,体温39～40℃,热程5～7天,间隔20～30天。发热期间四肢关节疼痛,尤以指、趾关节为甚。既往体健。查体:T39.2℃P106次/分,R20次/分,Bp14.7/10.7kPa无皮疹,表浅淋巴结无肿大。心脏及双肺正常。肝未触及,脾肋下2.0cm,质中,无触痛。全腹无压痛。关节无肿胀、畸形。实验室及特殊检查:Hb106g/L,WBC2.8～4.2×10~9/L。ESR90mm/h。尿、便常规(-)。类风湿因子阴性。
Resident physician for the first round of rounds: ask the training physician to report a summary of the medical record. Training physician: patient, male, 35 years old. 8 months ago, began to appear polyuria, polydipsia, drink more, good hunger eat more, fatigue, weight loss. Two-finger joint pain. No abdominal pain, diarrhea. Cyclical fever occurred in recent 3 months, body temperature 39 ~ 40 ℃, heat 5 to 7 days, 20 to 30 days interval. Extremity joint pain during fever, especially in the fingers, toe joints is even worse. Past physical health. Examination: T39.2 ℃ P106 times / min, R20 beats / min, Bp14.7 / 10.7kPa no rash, no swelling of the superficial lymph nodes. Heart and lungs normal. Liver did not touch, spleen ribs 2.0cm, quality, no tenderness. All-abdominal no tenderness. Joints without swelling, deformity. Laboratory and special examination: Hb106g / L, WBC2.8 ~ 4.2 × 10 ~ 9 / L. ESR90mm / h. Urine, then routine (-). Rheumatoid factor negative.