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病历摘要刘××,男,25岁。因咳嗽、心慌、气急渐加重2个月来院就诊。门诊拟诊为“支气管感染”,给予青霉素,链霉素抗炎治疗而无效。一周后上述症状加重且双下肢浮肿,夜间不能平卧而再次就诊。胸透两肺淤血,心影增大,搏动减弱,以“充血性心肌病合并Ⅲ度心衰”收入院。患者智力差。两个妹妹,其中大妹生得矮小,在14岁时死亡,死因不明。现有一妹妹15岁,身材矮小(130cm),读小学四年级,成绩中下。父母身体健康,身高及智力均正常。非近亲结婚,否认家族中有
Medical record summary Liu × ×, male, 25 years old. Due to cough, palpitation, Qi Jian gradually increase the hospital for 2 months. Outpatient consultation diagnosed as “bronchial infection”, given penicillin, streptomycin anti-inflammatory treatment and ineffective. A week later, the symptoms worsened and lower extremity edema, can not be supine at night and treatment again. Thoracotomy two lung congestion, increased heart shadow, impulsive weakened, “congestive heart disease with Ⅲ degree heart failure” income hospital. Poor patient intelligence. Two younger sisters, including the younger sister, were born short and died at the age of 14 with unknown cause of death. The existing 15-year-old sister, short stature (130cm), the fourth grade, primary and secondary grades. Parents in good health, height and intelligence are normal. Non-relatives get married, denied the family