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患者王某,女48岁,社员。主诉:反复出现口腔粘膜及外阴部溃疡9年,近2个月症状加重。病史:1970年9月第一次开始出现口腔、外阴及睑结膜溃疡。1978年、1979年曾在我院住院治疗,诊断为白塞氏病,治愈出院。此次复发于1980年5月份,开始发热,继之出现口腔、外阴部溃疡伴有肿痛,近2个月症状加重,脓性分泌物增多,行走困难。未经治疗,来我院求治。病程中食欲佳,二便正常。检查:体温36℃,脉搏76次,血压120/80,神志清楚,表情痛苦。全身皮肤无出血点,口腔粘膜光滑,舌较肿大,两缘分别有2个高粱粒大溃疡面,扁桃体不肿大。两肺呼吸正常,心界不扩大,心尖区可闻及Ⅱ级收缩期舒张期杂音,律齐。腹软,肝脾未触及。关节无红肿。妇科情况:左侧小阴唇破溃,左侧外阴可见约6×8×2cm溃疡面,深2cm,表面覆以较多脓苔(未做培养与涂片),未做内诊。诊断(1)白塞氏病,以外阴溃疡为主;(2)风湿性心脏病,二尖瓣狭窄,二尖瓣关闭不全。入院后给1:
Patient Wang, 48-year-old female member. Chief complaint: recurrent oral mucosa and vulvar ulcers for 9 years, nearly 2 months symptoms worsened. History: The first oral, vulvar and conjunctival ulcer started to appear in September 1970. In 1978, 1979 hospitalized in our hospital, diagnosis of Behcet’s disease, cured and discharged. The recurrence in May 1980, began to fever, followed by the emergence of the mouth, vulvar ulcers associated with swelling and pain, the past two months increased symptoms, increased purulent secretions, walking difficulties. Untreated, to our hospital for treatment. Good appetite in the course of the disease, two will be normal. Check: body temperature 36 ℃, pulse 76 times, blood pressure 120/80, conscious, facial expression pain. No skin bleeding, oral mucosa is smooth, the tongue is swollen, two limbs, respectively, two sorghum large ulcer surface, tonsil does not enlarge. Breathing normal both lungs, heart does not expand, the apex area can be heard and Ⅱ systolic diastolic murmur, law Qi. Abdomen soft, liver and spleen not touched. Joints without swelling. Gynecological conditions: left labia minora ulceration, the left vulva can be seen about 6 × 8 × 2cm ulcer surface, 2cm deep, the surface covered with more pus moss (not culture and smear), not done in consultation. Diagnosis (1) Behcet’s disease, mainly vulvar ulcers; (2) rheumatic heart disease, mitral stenosis, mitral regurgitation. After admission to 1: