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病历摘要:患者,男性,62岁,1985年10月25日曾发作急性心肌梗塞,缓解后仍感胸闷,动则气喘。近一个月余常有夜间阵发性呼吸困难,两下肢浮肿。于1986年1月8日转入我院。检查:半卧位,重病容,呼吸急促。颈静脉充盈,两侧中下肺有散在细湿罗音,心界稍扩大,心率114次,有早搏,第一心音低钝,有舒张期奔马律,A_2>P_2,两下肢轻度浮肿.血CPK1.1u,LDH476u.胸片:两肺纹增强,两下肺纹稍模糊,心影似有增大。扇型超声心动图检查:左室前壁运动减弱,左室扩大,左心功能不全(心电图见插页图1、2)。
Medical record summary: The patient, male, aged 62, had an episode of acute myocardial infarction on October 25, 1985, with chest tightness and wheezing after remission. Nearly a month I often have paroxysmal nocturnal dyspnea, both lower extremities edema. On January 8, 1986 into our hospital. Check: semi-recumbent, seriously ill, shortness of breath. Jugular vein filling, both sides of the middle and lower lung scattered in the fine wet rales, heart slightly expanded heart rate 114 times, with premature beats, the first heart sound low blunt, diastolic gallop, A_2> P_2, both lower extremity mild Edema. Blood CPK1.1u, LDH476u. Chest X-ray: two lung pattern enhancement, two lung pattern slightly blurred, heart shadow seems to have increased. Fan-type echocardiography: left anterior wall motion weakened, left ventricular enlargement, left ventricular dysfunction (ECG see insert Figure 1, 2).