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1 病历摘要患儿女,13岁。因气短、轻咳10余天,喘憋、烦躁1天,于1994年8月11日急诊入院。院外曾按上感用青霉素等治疗无好转。无少尿、血尿、视力障碍及抽搐。否认结核接触史,未接种过卡介苗。查体:体温37.3℃,脉搏152次/分,呼吸40次/分,血压22/16kPa。发育营养欠佳。神志清,端坐位,烦躁,多汗,有喘憋。眼睑水肿,口唇青紫。两肺闻及细小水泡音,心界向左明显扩大,心音低钝,呈奔马律,腹平坦,肝肋下2.0cm,肝颈逆流征(+),脾未触及,胫前指压痕(-)。甲床有紫绀。
1 medical records with children, 13 years old. Due to shortness of breath, light cough 10 days, wheezing, irritability 1 day, on August 11, 1994 emergency admission. Outside the hospital had been treated with penicillin and other no improvement. No oliguria, hematuria, visual impairment and convulsions. Denied the history of tuberculosis contact, not vaccinated BCG. Physical examination: body temperature 37.3 ℃, pulse 152 beats / min, breathing 40 beats / min, blood pressure 22 / 16kPa. Poor nutrition. Conscious, sitting, irritability, sweating, wheezing. Eyelid edema, purple lips. Two lungs and small blisters sound, the heart bound to the left significantly expanded, low heart sound blunt, galloping, belly flat, liver ribs 2.0cm, liver reflux syndrome (+), spleen not touched, anterior tibia finger indentation (-). A bed of cyanosis.