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病历摘要女性、5岁、因咳嗽1月,并全身浮肿、气喘、少尿4天入院。患儿系第二胎足月产、混合喂养,出生15天后反复患呼吸道感染,病史中无“心脏杂音”及“心脏病”记载。父母体健,母妊娠期无发热及特殊用药史。体捡体温正常,营养发育较同龄儿童稍差,面部及双下肢轻度凹陷性水肿,四肢末端及唇周无紫绀,咽部充血,颈静脉充盈,左胸廓饱满,双肺呼吸音粗,双肺底可闻及细湿罗音,心界向左侧扩大,心尖搏动在第五肋间锁骨中线外,搏动弥散,心率136次/分
Female medical record, 5 years old, due to cough January, and systemic edema, asthma, oliguria 4 days admission. Children with second-term full-term infants, mixed feeding, repeated respiratory tract infection 15 days after birth, no history of “heart murmur” and “heart disease” records. Parents physical health, mother’s pregnancy without fever and special medication history. Body picking normal body temperature, nutrition development is slightly worse than children of the same age, facial and lower limb mild pitting edema, extremities and lips without cyanosis, throat congestion, filling the jugular vein, left thorax full, lung breath sounds coarse, double The bottom of the lung can be heard and fine wet rales, heart to the left to expand, apex beat in the interclavicular clavicle midline, pulsatile dispersion, heart rate 136 beats / min