病史报告示范 | 类风湿心包炎

小白老师说：The case is a 60-year-old man admitted because of dyspnea and pulmonary vascular congestion. 该病例为一名60岁的男性，因呼吸困难和肺淤血收入院。

Case Presentation

The patient had reportedly been well until five days earlier, when he began to have dyspnea during moderate exertion. Two days before admission, he felt a nonradiating heavy discomfort in the lower retrosternal and epigastric areas when he stooped, bent over or walked short distances. There was no orthopnea, sweating, nausea, or edema.

病人入院5天前情况良好，后于中等体力活动时开始出现呼吸困难。入院前2天，病人在俯身、弯腰或短距离行走时，感胸骨下端与上腹部沉重感，无放射痛。无端坐呼吸、大汗、恶心或水肿。

On admission, the blood pressure was 150/70 mmHg. The pulse was 80 to 90 beats per minute (bpm) and irregular. Inspiratory crackles were heard at both lung bases, and a grade 1 systolic murmur was audible. The abdomen was normal, and there was no peripheral edema. Laboratory tests were performed. The hematology laboratory data and blood chemical values were almost normal. The levels of creatine kinase MB were normal twice that day, as was the level of troponin. The levels of urea nitrogen, creatinine, glucose, calcium, magnesium, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase were normal.

入院时，血压为150/70mmHg，心率80~90次/分，律不齐。两肺底闻及吸气相湿罗音，心脏听诊可闻及1级收缩期杂音。腹部未发现明显异常，无外周水肿。进行相关实验室检查，血液学和神话检查未见明显异常。当日2次肌酸激酶同工酶检查正常，肌钙蛋白也正常。尿素氮、肌酐、葡萄糖、钙、镁、门冬氨酸氨基转氨酶、丙氨酸氨基转氨酶、碱性磷酸酶均正常。

An electrocardiogram showed atrial flutter with high-degree atrioventricular block and ventricular ectopic eats, as well as delayed R-wave progression in leads V1 through V4, without abnormal Q waves, and diffuse nonspecific ST-segment and T-wave abnormalities. A chest radiograph was said to have shown cardiac enlargement and lower-lobe infiltrates, suggesting the presence of congestive heart failure. An injection of furosemide was followed by satisfactory diuresis, with resolution of the retrosternal and epigastric discomfort.

心电图显示心房扑动伴高度房室传导阻滞、室性异位节律，以及R波在V1-V4导联中出现延迟，无异常Q波、广泛非特异性ST段与T波异常。胸片显示心影增大，两肺下叶浸润影，提示充血性心力衰竭。入院后经注射呋塞米后利尿效果良好，胸骨后及上腹部不适好转。

He had a long history of hypertension, for which he took verapamil. Many years earlier, he had smoked cigarettes, and he occasionally drank wine. Six years before admission, he underwent a stress test because of atypical chest pain; no abnormality was found except for a bout of supraventricular tachycardia, and digoxin therapy was begun at that time. At the same year, a cardiac ultrasonographic study revealed slight left atrial enlargement, slight dilation of the aortic root, without aortic regurgitation, and slight pulmonic regurgitation. Another stress test, two years before admission, showed no abnormalities. About one year before admission, the patient had a brief episode of atrial fibrillation, which subsided spontaneously.

病人有长期高血压病史，服用维拉帕米。已戒烟多年，少量饮酒。6年前，因不典型胸痛进行运动平板试验，除阵法室上性心动过速未见其他异常，后开始服用地高辛。同年的一次心超检查提示轻度左方扩大、主动脉根部轻度扩张，不伴主动脉瓣反流，轻度肺动脉瓣反流。入院2年前的另一次运动平板试验未见明显异常。入院前1年出现阵发性心房颤动，未治疗，后自行消退。