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病历摘要刘××,男性,30岁,住院号15819。因心悸、气短、痰中带血1月余,于1979年3月12日入院。自诉1月前因下塘捕鱼,次日突感寒战、高热。口服感冒药后热稍退,但感心悸、气短,特别在活动时加重。在当地医院治疗诊断为“风湿性心脏病”。用青、链霉素及洋地黄治疗,效果不佳,于2月24日自动出院。3月4日起气短、咳嗽加剧,痰中带血,胸痛,伴有两下肢浮肿,尿少,纳差。近二天来,呼吸困难严重,夜间不能平卧,病情逐日加重,而来我院
Medical record summary Liu × ×, male, 30 years old, hospital number 15819. Due to heart palpitations, shortness of breath, bloody sputum more than 1 month, on March 12, 1979 admitted. Private prosecution due to pond fishing January, the next day suddenly chills, fever. Oral cold medicine fever slightly back, but feeling palpitations, shortness of breath, especially in activities increased. Treatment at a local hospital diagnosed as “rheumatic heart disease.” With blue, streptomycin and digitalis treatment, the effect is not good, was discharged automatically on February 24. March 4 shortness of breath, increased cough, bloody sputum, chest pain, accompanied by lower extremity edema, oliguria, anorexia. Nearly two days, severe breathing difficulties, supine at night can not, the condition worsened day by day, but to our hospital