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男,51岁,患者入院前4个月无明显诱因反复出现寒战,高热,体温最高达41℃,一天温差可达5℃,伴有心悸、气促,咳嗽、咳痰、尿少、下肢浮肿,在当地治疗1个半月前始又再出现寒战、高热,体温持续不退,遂转我院。有风湿心史20多年。体查:T37.8℃,R26次,P68次,BP14/8kPa,神智清,慢性重症病容,贫血貌,口唇发绀,下唇粘膜见数个出血点,心尖搏动于左锁骨中线第6肋间外1.5cm,可触及收缩期震颤,叩诊心界向左下及右侧扩大,心率105次,律不整,快慢不一,强弱不等,心尖区可闻收缩期Ⅲ级粗糙吹风样杂音及中等强度舒张期隆隆样杂音,双肺(一),肝大右肋下4cm,脾不大。血常规;红细胞2.04×10~(10)/L,血红蛋白55g/L,
Male, 51 years old, 4 months before admission, there is no obvious incentive for repeated chills, fever, body temperature up to 41 ℃, one day temperature difference of up to 5 ℃, accompanied by palpitations, shortness of breath, cough, sputum, oliguria, lower extremity edema , In the local treatment 1 and a half months ago there began to chills, fever, body temperature continued, then transferred to our hospital. A history of rheumatic heart more than 20 years. Physical examination: T37.8 ℃, R26 times, P68 times, BP14 / 8kPa, Shenzhi Qing, chronic severe disease, anemia appearance, lips cyanosis, lower lip mucosa see several bleeding points, apex beat in the left subclavian midline 6th intercostal space Outside 1.5cm, can reach systolic tremor, percussion heart to the left and right to expand the heart, heart rate 105 times, the law is not uniform, varying in speed, strength range, apex symphony Ⅲ can be heard rough hair-style noise and moderate Intensity of diastolic rumbling noise, lung (a), the right large rib 4cm, spleen is not large. Blood routine; red blood cells 2.04 × 10 ~ (10) / L, hemoglobin 55g / L,