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患者男,65岁。反复咳嗽、咳痰3年(持续2～3个月/年),经抗生素治疗后病情改善。6天前因受凉后感上述症状加重,伴发热、胸痛、气促(以活动时为甚)。体检:体温37.8℃,脉搏108次/min,R 22次/min,Bp 105/75 mmHg(1 mmHg=0.133 kPa)。右肺呼吸音低,可闻及干湿啰音。心音低钝,心律齐无杂音。腹部肝脾未触及,肠鸣音存在。临床诊断:慢性支气管炎并肺部感染;肺源性心脏病。
Male patient, 65 years old. Repeated cough, sputum for 3 years (continued for 2 ~ 3 months / year), the condition improved after antibiotic treatment. 6 days ago due to cold feeling of the above symptoms worse, with fever, chest pain, shortness of breath (to activities). Physical examination: body temperature 37.8 ℃, pulse 108 beats / min, R 22 beats / min, Bp 105/75 mmHg (1 mmHg = 0.133 kPa). Right lung breath sounds low, can be heard and wet and dry rales. Low heart sound blunt, heart rhythm Qi no noise. Abdominal liver and spleen not touched, bowel sounds exist. Clinical diagnosis: chronic bronchitis and pulmonary infection; pulmonary heart disease.