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病历摘要男,54岁,农民,因咳嗽呼吸困难伴双下肢水肿半月入院,原有肺心病史10年,诊为慢性肺心病急性发作。入院后给予低盐饮食,口服双氢克尿噻、氨体舒通消水肿,用点滴青霉素、氨苄青霉素(加入10％葡萄糖中)抗感染等治疗1周,咳嗽,呼吸困难明显减轻。近2日病人出现厌食,恶心呕吐,精神淡漠,嗜睡,逐渐神志不清。查体:T36℃,P110次/分,BP16/12kPa呼吸稍促,口唇无紫绀,颈软,无颈静脉怒张,双肺底有少许干罗音,心突搏动于剑下,心率110次/分,律整,剑下可及收缩期Ⅱ级吹风样杂音,肝脾未及,双下肢无水肿,全身肌张力低下,膝腱反射减弱,无病理反
Summary of medical records Male, 54 years old, farmer, due to cough and difficulty breathing with lower extremity edema admitted for half a month, the original history of pulmonary heart disease for 10 years, diagnosed as acute episode of chronic pulmonary heart disease. After admission to give low-salt diet, oral hydrochlorothiazide, ammonia Shu Tong eliminate edema, with penicillin, ampicillin (add 10% glucose) anti-infection treatment for 1 week, cough, dyspnea was significantly reduced. Nearly 2 patients with anorexia, nausea and vomiting, apathy, lethargy, and gradually unconscious. Physical examination: T36 ℃, P110 beats / min, BP16 / 12kPa breath slightly, no cyanosis of the lips, neck soft, no jugular venous distention, a little lung at the end of dry rales, cardiac pacing beating sword, heart rate 110 / Min, the law, the sword can be systolic grade Ⅱ and hair-style noise, liver and spleen not, no lower extremity edema, lower body muscle tone, knee tendon reflexes, no pathological