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患者,女性,18岁,工人。主因发热伴四肢关节疼痛6月余入院。于1986年9月始,反复发热,四肢关节疼痛并出现双手红斑。门诊化验抗核抗体阳性,肝功能异常,丫球蛋白增高(28%),抗链“O”阴性,血中未找到狼疮细胞。经门诊抗风湿治疗未能控制,于1987年3月28日住院。查体:体温37.8℃,脉搏108/min,呼吸25/min,血压15/llkPa。发育正常,营养稍差,慢性病容,颜面未见狼疮性皮肤损害。两肺清音,心界不大,律齐,心率110
Patient, female, 18 years old, worker. Mainly due to fever with limbs and joints pain more than 6 months admitted to hospital. Beginning in September 1986, repeated fever, limbs and joint pain and erythema with both hands. Outpatient laboratory anti-nuclear antibody-positive, abnormal liver function, increased myoglobin (28%), anti-chain “O” negative, the blood can not find lupus cells. Outpatient anti-rheumatic treatment failed to control, in March 28, 1987 hospitalization. Physical examination: body temperature 37.8 ℃, pulse 108 / min, breathing 25 / min, blood pressure 15 / llkPa. Normal development, nutrition is slightly worse, chronic disease, no lupus skin damage. Clear voice of both lungs, heart is not big, law Qi, heart rate 110