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患女,43岁。因双眼视力下降1月,发热咳嗽1d,于1996年4月23日入院。1月前因劳累出现双眼视力急剧下降(0.4),测血压22/14kPa,眼底示明显A-V交叉压迹,盘缘及后枕部网膜可见点片状出血。诊断为高血压病Ⅲ期,眼底出血,经降压(复方降压胶囊,开搏通),止血等治疗后血压未控制,且心慌气短,VCG示大量心包积液1d前咯白色稀痰,发热(38.6℃)。既往对青霉素、磺胺、先锋霉素、舒普罗均过敏。查体;T38.6℃,P100次/min,R18次/min,BP23/13kPa。口唇无发绀,无颈静脉怒张,双肺(-),心界向左扩大,双下肢不肿。实验室检查RBC3,11×10~(12)/L,WBC2.9×10~9/L,PC61×10~9/L,ESR98mm/b。尿蛋白(+++),潜血(+)。入院诊断:发热原因待诊,结缔组织病?慢性肾炎,高血压病Ⅲ期。
Female, 43 years old. Due to decreased binocular vision in January, fever, cough 1d, on April 23, 1996 admission. 1 month ago due to fatigue, binocular vision decreased sharply (0.4), blood pressure 22 / 14kPa, fundus showed obvious A-V cross-indentation, disc edge and posterior occipital retinal bleeding can be seen flaky. Diagnosis of hypertension stage Ⅲ, fundus hemorrhage, the blood pressure (compound antihypertensive capsule, Caipont), hemostasis and other treatment after the blood pressure was not controlled, and palpitation shortness of breath, VCG showed a large amount of pericardial effusion 1d slightly thin phlegm, Fever (38.6 ℃). Previous to penicillin, sulfonamides, cephalosporins, Sulpirone are allergic. Examination; T38.6 ℃, P100 times / min, R18 times / min, BP23 / 13kPa. No cyanosis of the lips, no jugular vein engorgement, lung (-), left to expand the heart, both lower extremity is not swollen. Laboratory tests RBC3, 11 × 10 ~ (12) / L, WBC2.9 × 10 ~ 9/L, PC61 × 10 ~ 9/L, ESR98mm / b. Urinary protein (+++), occult blood (+). Admission diagnosis: causes of fever pending diagnosis, connective tissue disease? Chronic nephritis, hypertension Ⅲ.