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患儿,男,8岁,因受凉后咽痛、发热半月,伴腹痛、呕吐与大便有蛔虫,于1978年4月21日住某县医院,经抗感染及驱虫等治疗13天,病情逐渐加重,出现心悸、气急,听诊心律不齐。体检:体温37.5℃,血压80/50mmHg,急性重病容,神萎靡,而色苍白,咽充血,扁桃体肿大Ⅰ°。心尖搏动弥散,心界向两侧扩大,心率90次/分,律不齐,心音低钝,心尖区有Ⅲ级收缩期杂音,肝肋下4cm、剑下3cm,触痛。WBC 15.2×10~9/L,中性66%。X 线胸透心脏呈普大型,搏动减弱,仰卧位心底不增宽。临床诊断:病毒性心肌炎。
Children, male, 8 years old, due to cold sore throat, fever half a month, with abdominal pain, vomiting and stool have roundworm, on April 21, 1978 live in a county hospital, anti-infective and deworming treatment for 13 days, the disease Gradually increased, palpitations, shortness of breath, auscultation arrhythmia. Physical examination: body temperature 37.5 ℃, blood pressure 80 / 50mmHg, acute serious illness, apathetic, and pale, pharyngeal congestion, tonsil enlargement Ⅰ °. Apex beating dispersion, the heart bound to both sides of the expansion, the heart rate 90 beats / min, irregular arrhythmia, blunt heart sound, apical systolic murmur Ⅲ, liver ribs 4cm, 3cm under the sword, tenderness. WBC 15.2 × 10 ~ 9 / L, neutral 66%. X-ray thoracic heart was a large, beating weakened, supine position is not widened heart. Clinical diagnosis: viral myocarditis.