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患者,男,24岁,因气短3年,浮肿,乏力4月入院。病后曾在院外按“风湿性心脏病二尖瓣狭窄”治疗无效而转本院。 查体:T38.2℃,P104次/min,R25次/min,BP13/8kPa。端坐呼吸,重度贫血貌,口唇苍白,两小腿见较密集出血点,新旧不一。全身浅表淋巴结不肿大。颈静脉明显怒张,颈软,甲状腺不大,气管居中,胸廓无畸形,胸壁无静脉怒张,两肺呼吸音粗,中下野可闻及中小湿罗音。心界向两侧扩大,胸骨左缘第2、3肋问可触及收缩期震颤及震荡感,心律齐,心率104次/min,心音有力,在胸骨左缘2、3肋间处可闻及Ⅲ级收缩期喷射性杂音及舒张期叹气样杂音,周围血管征阴性。腹稍膨隆,无腹壁静脉怒张,肝肋下3.0cm,质软,触痛,肝颈回流征阳性。脾肋下6.0cm,质中,压痛可疑。双下肢压陷性水肿。血常规:WBC2.8×10~9/L,N0.68,RBC1.5×10~()/L,Hb40g/L,ESR118mm/h,抗“O”500U以上,风湿因子阳性。尿常规蛋白(+),潜血(+++),肝功正常。连续3次血培养无菌生长。心脏片示:双室大。心电图示:不完全右束支阻滞。
The patient, male, 24 years old, was admitted to hospital in April because of shortness of breath for 3 years, edema, and fatigue. After the illness, she was referred to the hospital after she was treated with “rheumatic heart mitral stenosis” outside the hospital. Physical examination: T38.2°C, P104/min, R25/min, BP13/8kPa. Sitting breathing, severe anaemia appearance, pale lips, two lower legs see more dense bleeding, old and new. Superficial lymph nodes are not swollen. The jugular vein was obviously engorged, the neck was soft, the thyroid gland was small, the trachea was centered, the thorax was not deformed, there was no venous engorgement on the chest wall, the breath sounds were thick in the two lungs, and the middle and lower fields could be heard with small and medium wet rales. The heart boundary expands to both sides. The second and third ribs on the left edge of the sternum can touch systolic tremor and concussion. The heart rate is equal to heart rate 104 beats/min. The heart sound is powerful. It can be heard at the left and right intercostal spaces of the sternum. Grade III systolic ejection murmurs and diastolic sigh-like murmurs, negative peripheral vascular signs. The abdomen is slightly bulging, without abdominal venous engorgement, liver subcostal 3.0cm, soft, tender, positive liver neck back sign. Spleen ribs 6.0cm, quality, tenderness suspicious. Both lower limbs sag edema. Blood routine: WBC 2.8×10~9/L, N0.68, RBC1.5×10~(/L), Hb40g/L, ESR 118mm/h, anti-“O” 500U or more, rheumatoid factor positive. Urine routine protein (+), occult blood (+++), normal liver function. Three consecutive blood cultures grew aseptically. Heart film shows: double room. Electrocardiogram shows incomplete right bundle branch block.