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患者女,35岁。因心悸2月余入院。体检:脉搏98次/分,有短绌脉。颈静脉怒张。两肺无啰音。心律不齐,心率126次/分。心尖部可闻双期杂音,主动脉辦区可闻轻度舒张期杂音,P_2亢进。肝可触及,下肢有可凹性浮肿,血沉5mm/1小时。心电图示心房纤颤。诊断:风心病,二尖瓣狭窄及关闭不全,主动脉瓣关闭不全,心房纤颤,心衰Ⅱ度。
Female patient, 35 years old. Due to palpitations more than 2 months admitted to hospital. Physical examination: pulse 98 beats / min, a short pulse. Jugular vein engorgement. No auscultation in both lungs. Arrhythmia, heart rate 126 beats / min. Apex can smell two-phase murmur, the aorta can be heard mild diastolic murmur, P 2 hyperthyroidism. Liver palpable, lower extremity have concave edema, ESR 5mm / 1 hour. ECG shows atrial fibrillation. Diagnosis: rheumatic heart disease, mitral stenosis and insufficiency, aortic regurgitation, atrial fibrillation, heart failure Ⅱ degree.