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李某某,男、63岁,住院号84—3101,因心慌、上腹胀痛1年,加重伴浮肿10余天入院。10余天来,气短不能平卧,咳嗽,咯少许白痰,下肢浮肿。体检:双肺底可闻及湿鸣,心界向左下扩大,心音低,心率96/分,律不齐,可闻及频发早搏,心尖区可闻及Ⅲ级收缩期杂音和舒张期杂音,肝右肋下4Cm,剑下5Cm,腹水征(+),肝颈回流征(+),双下肢明显压陷性水肿,EKG:窦性心律,88/分,频发多源性室性早博。完全性右束枝传导阻滞伴右室大。胸部透视:风湿性心脏病联合瓣膜损害。入院诊断:风湿性心脏病,二尖
Lee Moumou, male, 63 years old, hospital number 84-3101, due to palpitation, abdominal pain for 1 year, aggravated with edema more than 10 days admitted. More than 10 days, shortness of breath can not lie, cough, slightly white sputum, lower extremity edema. Physical examination: the end of the lungs can be heard and dampness, the heart to expand to the lower left, low heart rate, heart rate 96 / min, irregular, can be heard and frequent premature beats, apex area can be heard and Ⅲ systolic murmur and diastolic murmur , Right subcostal 4Cm, Sword 5Cm, signs of ascites (+), liver reflux syndrome (+), significant subgingival compression edema, EKG: sinus rhythm, 88 / min, frequent multi-ventricular Bo morning. Complete right bundle branch block with large right ventricle. Chest perspective: rheumatic heart disease associated with valve damage. Admission diagnosis: rheumatic heart disease, two sharp