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临床资料 男,52岁。主诉五年来发作性心悸、气紧、盗汗,近年来发作频繁,多与劳累有关,每次发作约10余分钟,休息后可缓解。近二天来受凉感冒后全身酸痛,伴胸闷,心悸。体格检查:体温36.9℃,呼吸18次/分,血压110/70mmHg,发育正常,营养一般,咽部充血,心界不大,心脏各瓣区无病理性杂音,心率78次/分,肝脾未触及,胸透及血常规、血脂检查等均属正常范围。临床诊断:上呼吸道感染,心肌炎?
Clinical data Male, 52 years old. The main complaint in the past five years onset of heart palpitations, tight gas, night sweats, frequent seizures in recent years, and more with exertion, each episode for about 10 minutes after the rest can be alleviated. After a cold in the past two days cold sore body, with chest tightness, palpitations. Physical examination: body temperature 36.9 ℃, breathing 18 beats / min, blood pressure 110 / 70mmHg, normal development, general nutrition, throat congestion, the heart is not big, the heart valve area without pathological murmurs, heart rate 78 beats / min, liver and spleen Not touched, chest X-ray and blood, blood lipids, etc. are within the normal range. Clinical diagnosis: upper respiratory tract infection, myocarditis?