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病历摘要患者女性,40岁,农民。因鼻部疼痛、涕中带血5月余,于1977年6月21日入院。入院前5月余开始鼻痛,涕中带血,日渐加重。入院前1月余出现头痛、耳鸣、眼红、视物模糊及食欲减退,在他院诊治曾作鼻粘膜活检,报告为慢性炎症及巨细胞反应,经青、链霉素治疗,病情未见好转,出现不规则发热(38.5℃左右),咽喉疼痛,张口困难,心悸气促,关节疼痛,双下肢皮疹,体重减轻。病前体质素健。查体体温36.8℃,脉搏80次/分,呼吸20次/分,血压100/60mmHg,发育尚可,营养欠佳,神志清楚,颜面苍白,眼球略突出,球结合膜慢性充
Patient summary Female patient, 40 years old, farmer. Due to nasal pain, tears bloody more than 5 months, in June 21, 1977 admission. More than five months before admission nasal pain, tears bloody, increasing. Headache, tinnitus, jealous, blurred vision and loss of appetite occurred more than one month before admission. In his hospital, he was diagnosed with nasal mucosa biopsy and reported chronic inflammation and cytomegalovirus reaction. After treatment with cyanine and streptomycin, his condition did not improve , Irregular fever (about 38.5 ℃), sore throat, mouth opening difficulties, heart palpitations, shortness of breath, joint pain, lower extremity rash and weight loss. Pre-disease physique Su Jian. Physical examination temperature 36.8 ℃, pulse 80 beats / min, breathing 20 beats / min, blood pressure 100 / 60mmHg, development is acceptable, poor nutrition, conscious, pale face, slightly prominent eyes, conjunctival chronic filling