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第一次查房 实习医生报告病历:患者,男,36岁,农民。因劳累后心前区疼痛3月余,加重伴心悸、胸闷1周入院。体查:体温36.5℃,脉搏80次,呼吸20次,血压20/5.3kPa。发育正常。皮肤、结膜无瘀点,唇不绀。颈动脉搏动明显。心界向左下扩大,心尖搏动在胸左第6肋间锁骨中线外3cm,心率80次,律整。二尖瓣区闻及收缩期吹风样Ⅱ/Ⅵ级杂音及舒张期隆隆样杂音,无震颤;胸骨右缘第2肋间有Ⅳ/Ⅵ级舒张早期递减型哈气样杂音,向心尖传导。腹部无异常,周围血管征(+)。脊柱左侧弯,下肢无水肿。ECG窦性心律,左室肥厚并劳累。X线透视左室增大。
The first round of intern reports of medical records: patients, male, 36 years old, farmer. Due to exertion in precordial pain more than 3 months, increased with palpitations, chest tightness 1 week hospitalization. Physical examination: body temperature 36.5 ℃, pulse 80 times, breathing 20 times, blood pressure 20 / 5.3kPa. Normal development. Skin, conjunctival petechia, lip cyanosis. Carotid pulsation obvious. Heart to the left to expand, apical beating in the chest left intercostal clavicle midline 3cm, heart rate 80 times, law. Mitral valve area and syphilis-style hair-like blowing Ⅱ / Ⅵ noise and diastolic rumbling noise, no tremor; second intercostal right sternal Ⅳ / Ⅵ diastolic early Ha-like noise reduction, to the apical conduction. No abnormal abdomen, peripheral vascular sign (+). Left curvature of the spine, lower extremity no edema. ECG sinus rhythm, left ventricular hypertrophy and fatigue. X-ray left ventricular enlargement.