出科病例（A case）.docVIP

出科病例（A case） Name Chen Feiyang birthplace Taihe County Gender male professional farmer Age 20 years, admission date 2013-03-07 Nationality Han record date 2013-03-07 Marriage, medical history, statement and signature of the patient himself Incidence of solar terms, rain, address Taihe County, Miao Town Complaints: lumbosacral and double knee, ankle pain for more than half a year. Present medical history: the patient has no obvious reason to appear lumbosacral rigidity and pain before six months, and has improved after the event, and has not paid attention to it. The lumbosacral stiff feeling were worse than before, and the emergence of double knee double ankle pain and discomfort, with no adverse events, half a month ago double ankle swelling, cause pain, back to my hospital HLA-B27 positive, sacroiliac joint MRI had no obvious abnormalities, ESR, C reactive protein increased, for the sake of further treatment, today to our department for treatment, intends to hold arthromyodynia. In the course of fever, fatigue, rash, alopecia, no light allergy, sleep, appetite, stool two. Past history: general health status: general. History of disease: denying the history of congenital heart disease. History of infection: a history of denial of hepatitis or tuberculosis. Vaccination history: vaccination on time, no adverse effects of vaccination. History of surgical injury: denial of surgical trauma. History of blood transfusion: denial of blood transfusion history. History of drug allergy: denial of drug allergy history. Personal history: in origin, parasites and deny the history of water contact, no smoking and drinking. Obstetrical history / menstrual history: /. Family history: denying familial genetic history. Physical examination T36.4 P78 R18 BP110/70mmHg C / min / min General situation: the patient is conscious, normal development, physical examination cooperation, automatic body position. Skin and mucous membranes: normal color, no yellow skin, rash and subcutaneous blee