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患者女,75岁,因发作性心前区疼痛6年,加重7h于2001年9月7日入院。入院诊断:冠心病不稳定型心绞痛,心功能Ⅱ级,Ⅱ型糖尿病,合并泌尿系感染,糖尿病肾病,末梢神经病变。查体:T 38.2℃,P 82次·min~(-1),R 20次·min~(-1),BP 120/70mmHg,神志清,精神差,检查合作,对答切题,两肺可闻及散在干湿(口罗)音。心脏:心界不大,HR 82次·min~(-1),律齐,A2>P2各瓣膜未闻及杂音。蛙状腹,腹软,肝脾肋下未及。血象:WBC 14.0×10~9·L~(-1),N 0.83,L 0.17,尿:血
The patient, 75 years old, was admitted to hospital on September 7, 2001, for an additional 7 hours due to episodic pre-anorexia pain for 6 years. Admission diagnosis: unstable angina pectoris, cardiac function Ⅱ, type Ⅱ diabetes mellitus, urinary tract infection, diabetic nephropathy, peripheral neuropathy. Examination: T 38.2 ℃, P 82 times · min -1, R 20 times · min -1, BP 120/70 mmHg, the spirit of consciousness, poor spirit, check the cooperation, answer the question, the two lungs can be heard And scattered wet (mouth Luo) sound. Heart: heart is not big, HR 82 times min ~ (-1), law Qi, A2> P2 of the valve is not smell and noise. Frog belly, abdomen soft, liver and spleen ribs did not. Blood: WBC 14.0 × 10 ~ 9 · L ~ (-1), N 0.83, L 0.17, urine: blood