Male, 70 years old, rheumatic heart disease cough, sputum, chest tightness, shortness of breath

(Patient's Name) :(Patient's Age) 70(Gender): Male: Rheumatoid Bone Diseasepatients admitted to hospital for 'coughing, coughing sputum, shortness of breath, chest tightness for 4 hours';'s current medical history"
patients who coughed, coughed, sputum, sputum, sputum, and sputum, Chest tightness (many years), the night can still lie flat rest (need side rest), dizziness, no fever, cold, no sleep wake, no chest pain, no nausea, vomiting, no abdominal pain, diarrhea, oral 'cough must clear tablets', the above symptoms no relief, 4 hours ago appearshort, chest tightness, continuity, oral 'quick-acting heart-saving pill' treatment, poor effect, for further diagnosis and treatmentSince the onset of the disease, the mind is clear, poor spirit, poor diet, sleep can be, two will not complain of abnormaldiagnosed in a large hospital'rheumatic heart disease' for many years; Month due toheart failurerepeated hospitalization, during the period (2015-05-10 this hospital) electrocardiogram: atrial fibrillation, ventricular early fighting, ST segment is ischemic type changes, incomplete right beam conduction blockHeart color super: rheumatic heart disease joint valve lesions, large heart, large number of two-tip valve reflux, three-tip valve large reflux, aortic valve a small amount of reflux, pulmonary valve small reflux, pulmonary artery high-pressure, heart-packfluid, left chamber contraction Reduced function (EF17%), incongruity of movement range, congenital heart disease, room gap defect (primary hole type); Allergies to 'sulfonamide' drugs, denial of '
diabetes, hypertension' history, denial of 'tuberculosis, hepatitis' and other infectious diseases, no major trauma and surgery history, denial of blood transfusion history, denial of food allergy history, prevention vaccination history is unknown check T:36.6C, P:77times/Min, R:19times/Min, BP:160/90mmhg God Qing, poor spirit, breathing is still stable, automatic position, check body cooperation Double pupilist is large and other round, sensitive to light reflection, mouth and lips slightly purple, tongue in the middle, two-sided neck veinanger, neck soft no resistance, trachea center, thyroid is not large The chest is symmetrically undistorted, the breathing motion on both sides is consistent, no enhancement or weakening, quiver is equal, the double lung breathing sound is coarse, the double lung is low audible and wet, the heart rate is 85 times / minute, the heart rhythm is absolutely inconsistent, the heart tone is not equal, the pulse is short, the hearing area of each valve can be heard and 3 degree systolic blow-like noise The abdomen is flat, no tenderness, no anti-jumping pain and muscle tension, about 8cm under the liver ribs, about 3cm under the sword, the spleen does not touch the swelling, Murphy (-), hepatic-neck vein reflux positive, abdominal drumtone, mobility turbidity negative, intestinal sound weak The skin on the front of the lower leg is dark, the superficial varicose veins, the double lower limb I refers to concave edema, the muscle strength of the limbs is 5 levels, the muscle tension normal, the two-sided babinski sign (-) "auxiliary examination" electrocardiogram: atrial fibrillation, ST-T segment change Preliminary Diagnosis 1 Chronic heart failure (acute exacerbation) heart function level 3 2 Bronchitis 3.
Arrhythmia atrial fibrosis (atrial fibrillation) 4 coronary atherosclerosis heart disease 5 varicose veins (double lower limbs) "differential diagnosis" acute ventricular pain: can have more severe and persistent pain in the frontal region, with Fever at the same time appear, breathing and coughing aggravated, early existing heart bag friction sound, systemic symptoms are generally not as serious as myocardial infarction serious; after the to give traditional, I-grade care to Chinese medicine, low-salt and low-fat diet, blood pressure measurement, oxygen inhalation, electrocardiogram monitoring, dynamic blood pressure testing, respiratory function monitoring, oxygen saturation monitoring; Rheumatic heart disease, short for wind heart disease, refers to the heart valve lesions caused by rheumatic heat activity , tired of the heart valve, the patient is wind heart disease and heart failure, to reduce the heart load, improve circulation-oriented; Doctor Source: CaseNetwork