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患者男,50岁,住院号1773。因反复咳嗽、咳痰、心悸1年,加重10天入院,1年前,病人因受凉出现咳嗽、咳痰,痰为白色泡沫状、感心悸、胸闷不伴胸痛及左肩放射痛,无四肢关节疼痛,即到我院一门诊求治,诊断为“风心病联合瓣膜损害(主动脉瓣和二尖瓣)”,经青霉素抗感染,能量合剂治疗,病情好转停药。以后每遇受凉病情复发,服药后(具体药名不详)又缓解。10天前因受凉出现活动后心累、气促,双下肢浮肿、尿少、伴有咳嗽,院外治疗无效收入我科。既往身体健康。
Male patient, 50 years old, hospital number 1773. Due to repeated cough, sputum, palpitations 1 year, increased 10 days admitted to hospital, 1 year ago, the patient appeared cold cough, sputum, sputum white foam, palpitations, chest tightness and left shoulder radiating pain, no limb joints Pain, that is to an outpatient treatment in our hospital, diagnosed as “rheumatic heart disease associated with valve damage (aortic valve and mitral valve)”, penicillin anti-infective, energy mixture therapy, the condition improved discontinuation. After each case of recurrent disease, medication (specific drug name is unknown) and ease. 10 days ago due to cold activities after the heart tired, shortness of breath, lower extremity edema, oliguria, accompanied by cough, hospital treatment ineffective income in our department. In the past, good health.