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病历摘要陈××,女性,22岁,未婚,社员主诉劳动后心跳气促多年。患者自幼劳动能力较差,快步行走或较重劳动后常有心悸、气促,但无咯血,晕厥及下肢浮肿史。除上述症状外,余无其他不适。体格检查:体温37℃,脉搏62次/分,血压100/68,体重48公斤。发育正常,营养中等,神志清楚,无发绀,无杆状指。五官检查无异常,甲状腺无肿大,颈静脉无怒张。胸廓外形无异常,心尖搏动在第5肋间锁骨中线处,心率124次。心脏听诊第二心音亢进,胸骨左缘第二肋间稍外有两期连续性机器样杂音,4°/6°,收缩期较响,伴震颤。髂外动脉及股动脉可闻枪击音,唇粘膜下可见毛细血管搏动。双侧膝反射存在,四肢脊柱无畸形。胸部X线检查:两肺纹理粗,肺门影增大,可见扩张性搏功。心呈二尖瓣型、中度增大,左心室增大、向左向后大,右心室略向前扩大。肺动脉段明显隆突,主动脉弓增宽,俩者之搏动均加强。整个心脏
Medical record Chen × ×, female, 22 years old, unmarried, members complained of shortness of breath after working for many years. Patients with poor working ability since childhood, walking or heavy labor often palpitations, shortness of breath, but no hemoptysis, syncope and lower limb edema history. In addition to the above symptoms, I have no other discomfort. Physical examination: body temperature 37 ℃, pulse 62 beats / min, blood pressure 100/68, weight 48 kg. Normal development, moderate nutrition, conscious, no cyanosis, no rod-like means. No abnormalities in facial features, no swelling of the thyroid gland, jugular vein without tension. No abnormal thorax shape, apex beat in the 5th intercostal clavicle midline, heart rate 124 times. Heart auscultation second heart sound hyperthyroidism, sternal left margin of the second intercostal slightly outside there are two consecutive machine-like noise, 4 ° / 6 °, systolic more loudly, with tremor. External iliac artery and femoral artery can be heard gunshot sound, capillaries visible under the lips mucosal pulsation. Bilateral knee reflex exists, limb deformity without spine. Chest X-ray examination: coarse texture of the two lungs, hilar enlargement, showing the expansion of sexual stroke. Heart was mitral valve type, moderate increase, left ventricular enlargement, left to right large, right ventricular slightly forward expansion. Significant pulmonary artery segment carina, aortic arch widened, both of the beats were strengthened. The whole heart