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病历摘要患者刘×,女,15岁,学生。住院号220195。1978年3月发现下肢皮肤多处出现红斑,硬节,局部疼痛。三天后红斑消退。继而发烧,体温39℃。关节酸痛,两天后热退。此后经常心悸,于同年6月15日入院。患者既往健康,无咽痛史。体检:血压120/70mmHg,脉搏116次/分,体温36.4℃。意识清楚,一般状态良好。皮肤未见红斑和结节,浅表淋巴结无肿大。咽部无异常。颈静脉无怒张。心界不大,心音纯,可听到频发期前收缩。双肺无异常。腹软,肝脾未触及。四肢关节无红肿,运动
Patient summary Liu ×, female, 15 years old, student. Hospital number 220195. In March 1978 found that multiple lower extremity skin erythema, hard knots, local pain. Three days later erythema subsided. Then fever, body temperature 39 ℃. Joint pain, two days after the heat back. Since then often palpitations, in the same year June 15 admission. Past patient’s health, no history of sore throat. Physical examination: blood pressure 120 / 70mmHg, pulse 116 beats / min, body temperature 36.4 ℃. Consciousness, generally good condition. No erythema and nodules of the skin, superficial lymph nodes without swelling. No abnormal throat. Jugular vein without tension. Small heart, pure heart sounds can be heard before the contraction period. No abnormal lungs. Abdomen soft, liver and spleen not touched. No joint swelling limbs, exercise