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患者,女,48岁,无慢性病和传染病史,无药物过敏史,既往有高血压、十二指肠溃疡病史,未做系统治疗。于2014年5月27日以“心悸、胸闷2天”为主诉就诊。查体:T:36.8℃,BP:130/90mmH g,P:62min-1,心律齐,各瓣膜听诊区未闻及病理性杂音,腹软,无压痛及反跳痛,肝脾未触及,神经系统检查未发现异常,心电图示:心肌缺血。初步诊断为:①原发性高血压(2级);②心肌缺血。给予降压、对症处理。处方:
The patient, female, 48 years old, had no history of chronic diseases and infectious diseases, had no history of drug allergy, had a history of hypertension and duodenal ulcer, and had not been treated systematically. On May 27, 2014, “palpitations, chest tightness 2 days ” as the main complaint. Check the body: T: 36.8 ℃, BP: 130 / 90mmHg, P: 62min-1, rhythm Qi, the valve auscultation area did not smell and pathological murmur, abdominal soft, no tenderness and rebound tenderness, Nervous system examination found no abnormality, ECG: myocardial ischemia. Initial diagnosis: ① essential hypertension (2); ② myocardial ischemia. Give blood pressure, symptomatic treatment. prescription: