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患女,55岁,农民,已婚。心悸4年,加重伴气短6月于1990年2月22日第3次入院。患者于4年前出现心慌,劳累后加重。今年2月起心慌加重,同时伴有咳嗽、气短。于十余天前曾以“风湿性心脏病、二尖瓣狭窄并关闭不全”诊断在我院住院治疗,5d 后好转出院。出院后第5d 又出现上述症状,且与体位有关,左侧卧位时可缓解。既往无关节痛等病史。查体:T36.5℃,P88次/min,R20次/min,BP12/10kPa。神清,自动体位,查体合作。颈静脉无明显怒张。两肺呼吸音粗糙。心界向左下扩大,心率88次/min,律齐,心尖区第一心音亢进,并可闻及舒张期隆隆样杂音和收缩期Ⅲ级柔和的吹风样杂音,未闻及扑落音。入院诊断:风湿性心瓣膜病,二尖瓣狭窄并关闭不全,心衰Ⅱ°。心电图提示:右室大,左室大不除外;M 超提示:风心病、二尖瓣狭窄伴关闭不全。ESR42mm/h。经强心、利尿等治疗十余天病情好转,15d 后,出现上腹胀闷,伴厌食。肝右肋下锁中线3cm,剑突下
Female, 55 years old, farmer, married. Palpitations 4 years, increased with shortness of breath in June on February 22, 1990 3rd admission. 4 years ago, patients with palpitation, exacerbated after exertion. Since February this year, palpitation increased, accompanied by cough, shortness of breath. More than ten days ago with “rheumatic heart disease, mitral stenosis and closed incomplete” diagnosis of hospitalized in our hospital, 5d improved after discharge. 5d after discharge and the above symptoms, and with the position, the left lateral position can be alleviated. Past history of joint pain and other non-related. Physical examination: T36.5 ℃, P88 times / min, R20 times / min, BP12 / 10kPa. Clear, automatic position, physical examination. No obvious jugular vein engorgement. Breathe sound rough between the two lungs. Heart to the left to expand, the heart rate 88 beats / min, law Qi, heart acupuncture first heart sound hyperthyroidism, and can be heard and diastolic rumbling-like murmur and systolic grade Ⅲ soft hair-like murmur, no smell and Sopranos. Admission diagnosis: rheumatic valvular disease, mitral stenosis and insufficiency, heart failure Ⅱ °. ECG prompt: large right ventricle, left ventricular greatly except; M-Tip: rheumatic heart disease, mitral stenosis with incomplete closure. ESR42mm / h. After cardiac, diuretic and other treatment more than ten days condition improved, 15d after emergence of abdominal distension boring, with anorexia. Right rib cage lock line 3cm, xiphoid