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第一次查房副主任医师:请实习医师报告病历实习医师:患者,女,63岁。低热、腹泻5月,1985年8月6日入院。1985年2月开始低热,体温37.6～38℃,食欲减退,大便次数增多,一日5～6次,但无腹痛和急胀感。6月下旬出现颜面及下肢浮肿,全身关节疼痛以右肩、腰为甚,与天气变化无关,下肢起小红疹痒感。曾诊断“类风湿性关节炎”,服中西药治疗无效入院。体检:T37.8℃,P100次/分,Bp120/70mmHg,消瘦,中度贫血外观,眼睑及下肢轻
The first rounds Deputy Chief Physician: Interns report medical history Intern: Patient, female, 63 years old. Low fever, diarrhea May, August 6, 1985 admission. February 1985 began fever, body temperature 37.6 ~ 38 ℃, loss of appetite, increased stool frequency, 5 to 6 times a day, but no abdominal pain and swelling sense. Appeared in late June, facial and lower extremity edema, joint pain to the right shoulder, waist is even more, has nothing to do with the weather changes, rash from the lower rash sense. Had diagnosed “rheumatoid arthritis”, serving Chinese and Western medicine invalid admission. Physical examination: T37.8 ℃, P100 beats / min, Bp120 / 70mmHg, weight loss, moderate anemia appearance, eyelid and lower limbs light