病历摘要患者男,46岁,已婚,干部,于1983年5月4日入院。患者1年前开始有劳累后气短、心悸,当地按“心脏病”给予镇静剂、维生素等治疗。半年前出现颜面、下肢浮肿、乏力、胃纳差,经当地医院治疗,浮肿减轻。6天前浮肿、心悸加重,咳嗽伴咯血,量少,暗红色。2天来心慌、气促,夜间不能平卧,日咯血2～3次,约150毫升,遂来住院。既往无风湿病及慢性咳嗽史。体查体温37.6℃,脉搏101次/分,呼吸26 Medical record Summary Male patient, 46 years old, married, cadre, was admitted on May 4, 1983. A year ago, patients began to have fatigue after a shortness of breath, palpitations, according to the local “heart disease” given sedatives, vitamins and other treatment. Appear six months ago, lower extremity edema, fatigue, poor appetite, the local hospital for treatment, edema to reduce. Edema 6 days ago, palpitations increased, cough with hemoptysis, less, dark red. 2 days to palpitation, shortness of breath, not supine at night, hemoptysis 2 or 3 times, about 150 ml, then hospitalized. Past no history of rheumatism and chronic cough. Body temperature 37.6 ℃, pulse 101 beats / min, breathing 26