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患者男性,29岁。因心慌、气短一年半,并胸闷、咳嗽、咯血丝痰一周,于1980年5月20日入院。起病后无畏寒、发热、浮肿等症状。既往体健,无发热、咽痛及游走性关节痛史。其母及姐数年前死于“心脏病”,详情不明体检T35.3℃,P84,R18,血压126/80。发育正常,营养中等,神清合作,安静平卧,皮肤无黄染或紫绀,无皮疹及出血点。全身浅表淋巴结不肿大。头颅及五官无异常。颈无抵抗,颈静脉不怒张。气管居中,胸廓对称,两肺未闻及干湿鸣。心尖搏动弥散,心界向左下扩大,心率84次/分,心律齐,胸骨左缘第3—4肋间可闻及收缩期喀喇音及Ⅲ级吹风样杂音。腹部平软,无压痛,肝脾未触及,无移动性浊音。两肾区无压痛及叩痛。关节无红肿。NS(一)。实验室检查血红蛋白8.5克,红细胞297万,白细胞7100,N60%,L38%,E2%,血小板6.3万,血沉95mm/h。心电图:左心室肥厚并劳损。超声心电图:左房室均增大,左室后壁与室间隔轻度增厚,二尖瓣CD 段呈吊床样改变。住院经过入院后诊断“原发性心肌病并发二尖瓣脱垂综合征”。于住院第10天开始不规则发热,游走性肩、膝、踝关节疼痛;大便每天10多次,含多量粘液,镜检:红细胞少量,脓细胞++;尿少,尿常规:蛋白++红细胞+,白细胞++;血NPN150mg%多次,全身出现散在出血性皮疹,面部有蝶形红斑;锒疮细胞+,确诊为系统性红斑狼疮(SLE)。给激素治疗及对症、支持疗法。病情不断恶化。入院第32天,死于消化道出血及肾功能衰竭。
Patient male, 29 years old. Due to palpitation, shortness of breath for a year and a half, and chest tightness, cough, hemoptysis sputum week, on May 20, 1980 admitted. After onset no chills, fever, edema and other symptoms. Past physical health, no fever, sore throat and migratory joint pain history. His mother and sister died of “heart disease” several years ago. The details of the unidentified medical examination are T35.3 ℃, P84, R18 and blood pressure of 126/80. Normal development, moderate nutrition, clear cooperation, quiet and supine, the skin without yellow dye or cyanosis, no rash and bleeding points. Systemic superficial lymph nodes are not enlarged. No abnormalities in the skull and facial features. Neck non-resistant, jugular vein does not anger. Tracheal center, symmetrical thorax, lungs did not smell both wet and dry Ming. Apex pulsation dispersion, the heart bound to expand to the left, heart rate 84 beats / min, arrhythmia, sternal left intercostal intercostal can hear symphonic sound and symphonic grade Kara and Ⅲ grade hair-like murmur. Abdomen soft, no tenderness, liver and spleen not touched, no mobility dullness. Two kidney areas without tenderness and percussion pain. Joints without swelling. NS (a). Laboratory tests hemoglobin 8.5 grams, 2.97 million red blood cells, white blood cells 7100, N60%, L38%, E2%, 63000 platelets, erythrocyte sedimentation rate 95mm / h. ECG: left ventricular hypertrophy and strain. Echocardiography: left atrioventricular increased, left ventricular posterior wall and ventricular septal mild thickening, mitral section of CD was hammock-like changes. Hospitalized after diagnosis of “primary cardiomyopathy complicated with mitral valve prolapse syndrome.” 10 days in the hospital began to irregular fever, migratory shoulder, knee, ankle pain; stool 10 times a day, with a large amount of mucus, microscopic examination: a small amount of red blood cells, pus ++; urine less urine routine: protein + + Red blood cells +, white blood cells + +; blood NPN150mg% many times, the whole body scattered hemorrhagic rash, facial butterfly erythema; scabies cells +, diagnosed with systemic lupus erythematosus (SLE). To hormone therapy and symptomatic, supportive therapy. The condition is deteriorating. The first 32 days of admission, died of gastrointestinal bleeding and renal failure.