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患者姜某、女性、48岁、敦化汉章山河村农民、病志号:40275。 该患于二十多年前患过“急性克山病”经当时抢救好转、此后二十年来常出现心悸、气短、胸闷、头晕、上述症状时轻时重、曾诊断过“风心病、心衰”,进行多次治疗。近三年上述症状加重,常出现下肢浮肿,不能从事日常家务劳动,自服“得心丸”速尿等药物免强维持生活自理。近三天出现左侧肢体全瘫,吐字不清.于1991年9月4日门诊以“风心病、心衰”、房颤、脑栓塞”收入院。 查体:T38.5℃、P120次/分不齐,R30次/分,BP13.3/9.33kpa呼吸急促、颜面浮肿,口唇发绀、左侧鼻唇沟变浅、伸舌左偏、颈亢抵抗,颈静脉充盈、双肺呼吸音弱,可闻及干
Patient Jiangmou, female, 48 years old, Dunhua Han Zhangshanhe village farmer, disease ID: 40275. The suffering from more than 20 years ago, “Acute Keshan disease” by the time the rescue was improved, then twenty years often palpitations, shortness of breath, chest tightness, dizziness, light weight when the above symptoms, had diagnosed “rheumatic heart disease Bad ”for multiple treatment. The past three years, the above symptoms worse, often lower extremity edema, can not engage in routine housework, self-service “reassuring pill” furosemide and other drugs to maintain their own lives free of charge. Appeared in the past three days on the left limb paralysis, articulation is unclear .In September 4, 1991 outpatient “rheumatic heart disease, heart failure,” atrial fibrillation, cerebral embolism "income hospital. Physical examination: T38.5 ℃, P120 / Points missing, R30 beats / min, BP13.3 / 9.33kpa shortness of breath, facial edema, cyanosis of the lips, the left nasolabial fissure shallow, left tongue extensor, hyperthyroidism resistance, jugular vein filling, lung breath sounds Weak, audible and dry