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一、病历摘要:病员男性,60岁,因心累心跳反复发作4年,复发加重3天入院。发病与气候改变和活动有明显关系。发病时,均有心悸、气短、咳痰和关节痛,双下肢偶有轻度水肿。检查患者慢性重病容,神智清楚,端坐呼吸,口唇轻度发钳,颈静脉怒张,肺底有湿罗音,心界向左下扩大,心律不齐,心音强弱不等,心尖区可闻Ⅲ级缩鸣和舒张期杂
First, the medical record summary: The patient male, 60 years old, heart attack repeated heart attack 4 years, recurrence increased 3 days admission. The incidence of climate change and activities have a clear relationship. Onset, both palpitations, shortness of breath, expectoration and arthralgia, occasional mild edema of both lower extremities. Chronic severe illness in patients with check, clear mind, sitting and breathing, lips mild hair clamp, jugular vein engorgement, lungs have wet rales, heart to expand to the left, arrhythmia, heart sound intensity ranging from apical area Smell grade Ⅲ contraction and diastolic miscellaneous