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患男,67岁。以全身皮肤硬化2年,加重伴咳嗽1周入院。2年前无明显原因皮肤粗糙、硬化,从四肢开始,渐波及全身。诊为进行性系统性硬化症,经中药治疗半年好转。1周前皮肤硬化加重,咳嗽、咯痰、进食差,大小便正常。查体:T37.8℃,P88次/min,R22次/min,BP16/8kPa。消瘦体质。四肢、胸背部皮肤变硬,萎缩,弹性差。胸廓呈桶状,叩诊过清音,双肺底可闻及细小湿鸣音。胸片示:双肺感染;心电图示:窦性心律伴频发室早,电轴不偏,低电压;血尿粪常规及肝肾功均正常。入院诊断:①进行性系统性硬化症;②肺气肿,肺炎;③心律失常:频发室性早搏。给以抗感染,改善微循环,支持对症治疗。静脉滴注头孢唑啉钠6.0g
Male, 67 years old. To systemic sclerosis 2 years, increased with cough 1 week admission. 2 years ago, no obvious reason for the rough skin, sclerosis, starting from the limbs, ascending and body. Diagnosis of progressive systemic sclerosis, the Chinese medicine improved six months. 1 week ago, sclerosis, cough, expectoration, poor eating, normal urine. Examination: T37.8 ℃, P88 times / min, R22 times / min, BP16 / 8kPa. Weight-loss constitution. Limbs, chest and back skin hardening, atrophy, poor flexibility. Thorax was barrel-shaped, percussion over the voiceless, the lungs can be heard at the end and the small wet song. Chest X-ray showed: double lung infection; ECG: sinus rhythm with frequent room early, the axis is not partial, low voltage; blood and urine stool routine and liver and kidney function are normal. Admission diagnosis: ① progressive systemic sclerosis; ② emphysema, pneumonia; ③ arrhythmia: frequent premature ventricular contractions. To anti-infection, improve microcirculation, symptomatic treatment support. Intravenous cefazolin sodium 6.0g