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患者邱××,男性,29岁,农民,住院号34655。因心悸、气促伴头晕、腹胀、下肢浮肿、尿少20余天,发热10天,于1986年7月21日入院。患者20天前开始逐渐感觉心悸、气促、头晕、腹胀、下肢浮肿、尿少,农村医生诊断为“肾炎”,用中草药治疗10~+天,症状反而加重,发热、气促不能平卧,来我院就诊。经检查血象发现幼稚细胞,胸部照片提示肺部感染右胸腔积液,而收住院,既往体健。查体:体温38℃,脉搏100次,出现奇脉,呼吸26次,血压120/90毫米汞柱,神清,急性重病容,半坐卧位,皮肤粘膜无黄染,无出血点及紫癜。颈部、腋下、腹股沟可触及多个小指头大淋巴结,可移动,无压痛,锁骨上下淋巴结无触及。咽充血(++),扁桃体Ⅰ°肿大,表面轻度糜烂,牙龈无出血。气管无明显移位,颈静脉怒张,肝颈静脉回流征(+)。右胸廓较饱满,胸骨叩击痛(+),右胸前第4肋以下
Patient Qiu XX, male, 29 years old, farmer, inpatient number 34655. Due to heart palpitations, shortness of breath with dizziness, abdominal distension, lower extremity edema, oliguria more than 20 days, fever 10 days, on July 21, 1986 admission. Patients began to feel palpitations gradually 20 days ago, shortness of breath, dizziness, bloating, lower extremity edema, oliguria, rural doctors diagnosed as “nephritis” with Chinese herbal medicine for 10 to + days, the symptoms have worsened, fever, shortness of breath can not lie down, Come to our hospital. After examination of blood found that naive cells, chest photographs suggest that the lung infection of the right pleural effusion, and admitted to hospital, past physical health. Physical examination: body temperature 38 ℃, pulse 100 times, appeared strange pulse, breathing 26 times, blood pressure 120/90 mm Hg, Shen Qing, acute serious illness, semi-sitting supine, skin mucosa no yellow dye, no bleeding and purpura . Neck, armpit, groin can reach multiple small finger large lymph nodes, removable, no tenderness, no contact with supraclavicular lymph nodes. Pharyngeal hyperemia (++), tonsil I ° swollen, mild erosion of the surface, no bleeding gums. Tracheal no significant shift, jugular vein engorgement, hepatic jugular vein reflux sign (+). The right thoracic more full, sternal percussion pain (+), the right chest below the fourth rib