1987年3月24日查房纪要——副主任医师请实习医生报告病历。实习医生杜×,男,52岁。因心悸、气短4年,低烧、关节痛1个月,意识不清4天,于87年2月28日入院。该患4年前即自觉劳累后心悸、气短,入院前1个月因感冒而心悸、气短加重,不能平卧,咳痰带血,伴低烧及双下肢水肿,时有恶心、呕吐,食欲不振,在家自服地戈辛无效。既往患风湿性关节炎病史10年。体检:T37.5℃、P86次/分、R22次/分,BP110/70mmHg。半卧位,口唇发绀,二尖瓣面容,神志清,呼吸急促。皮肤粘膜无黄染及瘀斑,全身浅表淋巴结无肿大。眼睑无浮肿,巩膜无黄染,双瞳等大同圆,对光反应灵敏,结膜无苍白。颈静脉怒张,气管居中,甲状腺不大,无项强。胸廓无畸形,双下肺叩诊浊音,呼吸音粗糙,双肺底可闻及 March 24, 1987 rounds minutes - deputy chief physician interns report medical records. Intern Du ×, male, 52 years old. Due to heart palpitations, shortness of breath 4 years, low-grade fever, arthralgia for 1 month, unconsciousness 4 days, on February 28, 1987 admission. 4 years ago, after suffering from palpitation, shortness of breath, 1 month prior to admission due to a cold and heart palpitations, shortness of breath, can not lie down, with bloody sputum, with low blood pressure and lower extremity edema, nausea, vomiting, loss of appetite , Self-serving Geusin invalid. Past history of rheumatoid arthritis 10 years. Physical examination: T37.5 ℃, P86 times / min, R22 times / min, BP110 / 70mmHg. Semi-recumbent position, lips cyanosis, mitral valve surface, conscious, shortness of breath. No yellow skin and mucous membrane ecchymosis, systemic superficial lymph nodes without swelling. Eyelid without edema, Sclera no yellow dye, double pupil Datong round, sensitive to light, no pale conjunctiva. Jugular vein engorgement, tracheal center, thyroid is not large, no items strong. No deformity of the thorax, double hypocalorical percussion dullness, rough breathing sounds, both lungs can be heard