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病历摘要患儿男,12岁。因气急,干咳,胸闷,心悸,腹胀,下肢水肿5个半月,于1986年8月15日第3次入院。前二次入院均诊断为“急性非特异性心包炎”,经反复心包抽液、抗炎及对症治疗,症状缓解而出院。体检:体温36℃,脉搏120次/分,有奇脉。呼吸42次/分,血压14.66/11.9kPa,呼吸困难,半卧位。头面部及下肢水肿,浅表淋巴结不大。颈静脉怒张,气管左移,右侧胸廓饱满,叩诊发浊,呼吸音减弱。
Summary of medical records Children male, 12 years old. Due to shortness of breath, dry cough, chest tightness, palpitations, abdominal distension, lower extremity edema 5 and a half months, on August 15, 1986 3rd admission. The first two admission were diagnosed as “acute non-specific pericarditis”, repeated pericardium pumping, anti-inflammatory and symptomatic treatment, relieve symptoms and discharged. Physical examination: body temperature 36 ℃, pulse 120 beats / min, Qi pulse. Breathing 42 beats / min, blood pressure 14.66 / 11.9kPa, breathing difficulties, semi-recumbent position. Head and face and lower extremity edema, superficial lymph nodes is not large. Jugular vein engorgement, left tracheal, right thorax full, percussion turbidity, decreased breath sounds.