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病历摘要女患,55岁,咳嗽,心悸10余年,于87年1月18日以慢性气管炎、肺气肿、肺心症收容入院。查体:神清语明,血压90/60mmHg,体温36.4℃,脉搏88次/分,吸呼20次/分。双肺底可闻中小水泡音。心率88次/分,律整,无杂音。肝于右肋下6cm,压痛(+),脾未触及,双下肢无浮肿。胸透:两肺纹理重,透光度增强。心电:右房肥大,心肌劳损。化验:WBC 8,900/mm~3,Seg69％,Ly31％。尿常规正常。肝功正常。电解质未查。
Medical history Abstract Female, 55 years old, cough, heart palpitations for more than 10 years, on January 18, 87 to chronic bronchitis, emphysema, pulmonary heart disease admitted to hospital. Physical examination: Clear statement, blood pressure 90 / 60mmHg, body temperature 36.4 ℃, pulse 88 beats / min, breathing 20 times / min. Double lungs can be heard in small blisters sound. Heart rate 88 beats / min, rhythm, no noise. Liver right ribs 6cm, tenderness (+), spleen not touched, no swelling of both lower extremities. Chest throat: heavy lung texture, enhanced transmittance. ECG: right atrial hypertrophy, myocardial strain. Laboratory: WBC 8,900 / mm ~ 3, Seg69%, Ly31%. Urine routine normal. Normal liver function. Electrolyte not checked.