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患者汤××,女性,63岁,退休工人,住院号14625。高血压史十余年。近年来胸骨后阵发痛频繁,夜间阵发性呼吸困难,话动后心悸、气短及下胺浮肿。82年曾诊为原发性高血压病(Ⅲ期),高冠心、心衰。平时服用降压药,BP160～180/90～100mmHg。本次因头痛头昏反复胸骨后闷痛一天,於83年7月18日夜急诊入院。体检:T36.5℃,P80次/分,BP230/120mmHg,体型肥胖,神清,下肢不肿,颈静脉不怒张,肺(-),心界向左下扩大,心率80次/分,律齐。未闻及杂音,肝脾不大,
Soup XX, female, 63 years old, retired worker, hospital number 14625. History of hypertension more than ten years. In recent years, frequent post-sternal bursts of pain, paroxysmal nocturnal dyspnea, then heart palpitations, shortness of breath and hypothyroidism. 82 years have been diagnosed as essential hypertension (Ⅲ), high coronary heart and heart failure. Usually taking antihypertensive drugs, BP160 ~ 180/90 ~ 100mmHg. This time because of headache dizziness repeated chest pain after one day, in July 18, 83 night emergency room admission. Physical examination: T36.5 ℃, P80 beats / min, BP230 / 120mmHg, body fat, Shen Qing, lower extremity is not swollen, jugular vein is not engorgement, lung (-), heart left to expand, heart rate 80 beats / Qi Unheard and murmur, liver and spleen is not big,