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患者 男,63岁,退休工。主因阵发性夜间呼吸困难1个月,伴纳差、腹胀2个月,于1990年4月4日入院。既往体健。查体:体温、血压正常,营养稍低下,双肺呼吸音粗,心界向左扩大,心音低钝,心率96次/分,律齐,肝肋下3cm,触痛(+),神经系统正常。化验三大常规,肝功能正常,血沉61mm/h,心电图显示:低电压,T波低平,右侧束传导阻滞;X线胸片显示:肺门纹理增重,右心室增大,左心膈角消失;B超显示左胸腔少量积液。初诊:心肌病,心功能不全,左侧胸膜炎,支气管感
Male patient, 63 years old, retired worker. Mainly due to paroxysmal nocturnal dyspnea 1 month, with anorexia, bloating for 2 months, on April 4, 1990 admitted. Past physical health. Physical examination: body temperature, blood pressure is normal, slightly lower nutrition, lung breath sounds coarse, heart left to expand, low heart sound blunt, heart rate 96 beats / min, law Qi, liver ribs 3cm, tenderness (+), nervous system normal. Three common laboratory tests, normal liver function, ESR 61mm / h, ECG showed: low voltage, T wave low flat, right bundle block; X-ray showed: hilar weight gain, right ventricular enlargement, left Diaphragmatic angle disappeared; B ultrasound showed a small amount of left chest fluid. First visit: cardiomyopathy, cardiac insufficiency, left pleurisy, bronchus