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第一次查房(3月4日) 住院医师:请进修医师报告病历。进修医师甲:男患,17岁。因紫绀加重1周,伴心悸、气短,于3月2日入院。患者自幼口唇发绀,活动后加剧,经休息可减轻。曾在当地拟诊先天性心脏病(下简称先心病)。此次起病无特殊菜食及服药,无发热、咳嗽、咯血、浮肿。其长兄亦有发绀史。查体:T36℃,R22次/分,P93次/分,BP100/60mmHg。巩膜皮肤无黄染及皮疹、口唇颜面及指端青紫,尤以口唇明显。浅表淋巴结不大,肺呼吸音增粗,心率93次/分,律齐、心前区可闻收缩期杂音Ⅱ—Ⅲ级。肝脾未扪及。脊往无畸形,四肢指趾端紧绀。实验室检
First rounds (March 4) Resident: Please study medical records. Training physician A: Male suffering, 17 years old. Due to cyanosis increased 1 week, with heart palpitations, shortness of breath, admitted on March 2. Patients with cyanosis lips since, aggravating activities, by rest can be reduced. Have been diagnosed with congenital heart disease (hereinafter referred to as congenital heart disease). The onset of special vegetables and medication, no fever, cough, hemoptysis, edema. His elder brother also had a history of cyanosis. Physical examination: T36 ℃, R22 times / min, P93 times / min, BP100 / 60mmHg. Sclera skin without yellow dye and rash, lips and fingertips bruising, especially with obvious lips. Superficial lymph nodes is not large, pulmonary breath sounds thickened, heart rate 93 beats / min, law Qi, presymbolic systolic murmur Ⅱ-Ⅲ level. Liver and spleen not palpable. Ridge to no deformity, limbs toe tight cyanosis. Laboratory test