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余某,男,50岁.因四肢关节疼痛,面部及全身皮肤发硬、肿胀、青紫,怕冷,而部变形于1978年冬在某医学院经皮肤病理检查确诊为硬皮病.近三月来胸闷、心慌、乏力,上楼气急,于1986年9月5日来院就诊.患者既往长期接触有机磷农药,无风湿病、高血压、冠心病及肾脏病等病史.无阳性家族史.查体:R20次、Bp110/70.面部无表情,两腭凹陷,面部及四肢皮肤色素沉着,其间有减退斑.双手不能握紧,右手中、小、无名指不能伸直.双下肢水肿.心界向双侧扩大,以左界明曼.HR70次,律不齐,心尖部闻及Ⅲ级收缩期杂音,主动脉第二听诊区闻及舒张期杂音,并向心尖传导、双肺(一)、实验室检查:Hb104g/L.尿
Yu Mou, male, aged 50. Due to joint pain in the extremities, the facial and systemic skin is stiff, swollen, bruising, and cold, while the deformity was diagnosed as scleroderma by percutaneous pathological examination in a medical school in the winter of 1978. Nearly three Months of chest tightness, palpitation, weakness, upstairs angst, came to hospital on September 5, 1986. Patients with long-term exposure to organophosphate pesticides, rheumatoid, hypertension, coronary heart disease and kidney disease and other medical history. No positive family history. Examination: R20 times, Bp110 / 70. Facial expression, the two palate hollow, facial and limb skin pigmentation, during which there are diminished spots. Hands can not hold tight, right hand, small, ring finger can not be straightened. Boundary to the bilateral expansion to the left boundary Mingman. HR 70 times, irregular arrhythmias, atrial and class Ⅲ systolic murmur, auscultation and diastolic second hearing auscultation and apical conduction, lung (a ), Laboratory tests: Hb104g / L. Urine