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田××,男,41岁,1989年11月13日因三年来活动后心悸气短、近半月症状加重,不能平卧而入院.入院前未接受洋地黄类药物治疗.查体:颜面及口唇发绀,颈静脉怒张、血压:94/70mmHg,心界大、心率:150次/分,律不整,心尖区第一心音减弱、可闻及Ⅲ/Ⅳ级吹风样收缩期杂音,肺动脉第一音亢进,双肺底水泡音.肝大右肋下2cm,双下肢浮肿,心电图:快速房颤、心动超声:左房左室明显增大,各瓣膜正常.胸片:心脏向两侧扩大.根据临床表现及辅助检查,诊断为扩张型心肌病、心衰Ⅱ°、快速房颤.
Field × ×, male, 41 years old, November 13, 1989 due to shortness of breath after three years of activity palpitations, nearly half of the symptoms increased, can not be supine and admitted to the hospital before admission did not receive digitalis medication. Cyanosis, jugular vein engorgement, blood pressure: 94 / 70mmHg, heart, heart rate: 150 beats / min, law is not the whole, the first heart area of apex weakens, can be heard and Ⅲ / Ⅳ grade hair-like systolic murmur, pulmonary artery A sound hyperthyroidism, the end of the lungs at the end of the blisters sound .Liver right rib 2cm, lower extremity edema, ECG: rapid atrial fibrillation, echocardiography: left atrial significantly increased left ventricular, the valve normal. According to clinical manifestations and laboratory tests, diagnosis of dilated cardiomyopathy, heart failure Ⅱ °, rapid atrial fibrillation.