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病史摘要患者王××,男,47岁,炮工,门诊号457.因体检发现心电图异常.自1972年起诊断为Ⅱ期矽肺.平素喜烟酒,身体尚健,能参加一般劳动.体检:血压106/76mmHg.两肺听诊呼吸音粗糙,心脏听诊无病理性杂音,卧位心律不齐,心率68次/分,肝肋下1.5cm,剑大2cm,无触痛,质中,脾未触及.实验室检查:血红蛋白14g%,白细胞计数4100,中性57%,淋巴41%,嗜酸性2%.尿常规阴性.血沉3mm/小时.肝功能检查正常范围.血总胆固醇、三酸甘油酯、抗“0”检查均正常范围.胸片:矽肺Ⅱ期,心膈正常.
History of patients Wang XX, male, 47 years old, artisan, outpatient number 457. ECG abnormalities found on the medical examination since 1972 was diagnosed as stage II silicosis.Pingzi like tobacco, the body is healthy, can participate in general labor. : Blood pressure 106 / 76mmHg. Two lung auscultation breathing sound rough heart auscultation without pathological murmur, lying arrhythmia, heart rate 68 beats / min, hepatic ribs 1.5cm, sword 2cm, no tenderness, quality, spleen Laboratory tests: hemoglobin 14g%, white blood cell count 4100, 57% neutral, lymphatic 41%, eosinophilic 2%. Negative urine. Erythrocyte sedimentation rate of 3mm / Glycerides, anti- “0 ” examination were normal range.X-ray: Silicosis Ⅱ, normal diaphragma.