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一、病历摘要患者男,13岁,广东东莞人,住院号4501。因发热4天,心悸6小时,于1982年8月6日入院。患者8月3日晚开始发热,体温38.5～40℃,伴头痛,无鼻塞、流涕及咳嗽、咳痰等症状。曾到我院门诊就诊,肌注青霉素及口服退热药无明显好转。8月5日晚觉心悸,继大汗淋漓,四肢发冷,呕吐,遗尿两次。8月6日晨急诊收入院。既往史无特殊。入院检查:体温36.4℃,呼吸24次/分,脉搏42次/分,血压70/50mmHg。面色苍白,四肢湿冷,急性重病容。咽稍充血,双侧扁桃体无肿大。胸廊无畸形,两肺呼吸音清。心前区无隆起,无心前区瀰漫性搏动;心界无明显扩大,心率42次,心律整,第一心音低钝,各瓣膜区未闻杂音。腹平软,肝脾未触及,腹无压痛,无移动性浊音。脊柱四肢无畸形,双下肢无浮肿,肛门、生殖器无特殊,神经系统检查无异常发现。心电图:Ⅱ°～Ⅲ°A-VB(房室传导阻滞)。
First, the medical record Summary Male patient, 13 years old, Dongguan, Guangdong, hospitalization 4501. 4 days due to fever, palpitations 6 hours, admitted on August 6, 1982. Patients started fever on the night of August 3, body temperature 38.5 ~ 40 ℃, with headache, no stuffy nose, runny nose and cough, sputum and other symptoms. I came to our clinic, muscle injection of penicillin and oral antipyretics no significant improvement. On the evening of August 5, palpitation, followed by sweating, extremities cold, vomiting, enuresis twice. Morning emergency hospital August 6. No previous history. Admission examination: body temperature 36.4 ℃, breathing 24 beats / min, pulse 42 beats / min, blood pressure 70 / 50mmHg. Pale, limbs cold and cold, acute serious illness. Pharyngeal slightly hyperemia, bilateral tonsils without swelling. Chest gallery without deformity, lung breath sounds clear. There was no uplift in the precordial area and no diffuse pulsation in the anterior precordial area. There was no obvious enlargement in the heart area, heart rate 42 times, whole heart rhythm, low first blunt sound and no noise in the valvular areas. Abdomen soft, liver and spleen not touched, abdominal no tenderness, no mobility dullness. Spine limbs without deformity, no swelling of both lower extremities, anus, genital no special, no abnormalities found in the nervous system examination. ECG: Ⅱ ° ~ Ⅲ ° A-VB (atrioventricular block).