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第一次查房(2月25日) 住院医师:请实习医师报告病历摘要。实习医师:患者,男,54岁.心悸、胸闷2—3年,劳累时加重半年余。曾因心悸,双下肢浮肿而到某医院诊为“风湿性心脏病”服用强心及利尿剂症状缓解,近月来劳累时除上述症状外,且有心前区隐痛不适感,无放射痛,无咯血.无外地长期居住史,无游走性关节肿痛史.1981年因患晶体脱位进行手术治疗.20岁结婚,婚后生育3男2女,现均健在.查体:身高1.68m,体重60kg,BP14.7/9.3kPa,无紫绀及浮肿.头颅无畸形,视力右0.08,左0.2,双瞳孔不等大,
First round of rounds (February 25) Resident: Interns request medical records summary. Intern: Patient, male, 54 years old. Palpitations, chest tightness 2-3years, Exacerbated when tired more than six months. Had due to heart palpitations, lower extremities edema and went to a hospital as a “rheumatic heart disease” taking cardiac and diuretic symptoms ease, in addition to the above symptoms in recent months when tired, and there is precordial pain and discomfort, no radiating pain, No history of long-term living outside, no migratory history of joint swelling and pain .1981 suffering from dislocation of the lens for surgical treatment .20-year-old married, married 3 male and 2 female, are now alive in. Physical examination: height 1.68m , Weight 60kg, BP14.7 / 9.3kPa, no cyanosis and edema. No deformity of the skull, visual acuity 0.08, left 0.2, double pupil ranging from large,