病历摘要袁××,女,10个月。因浮肿气促1个月,咳嗽1周,发热1天,于1979年10月26日第二次入院。患儿出生后半个月发现心杂音,在当地诊断为先天性心脏病(先天心)。因反复发热于1979年6月第一次来我院住院,经抗感染,一般对症处理,住院21天。诊断为:1.先天性心脏病(动脉导管未闭合并室间隔缺损;2.肺炎;3.夏季热。出院后偶有咳嗽、低热、浮肿。本次入院前1个月全身浮肿、尿少、烦躁、多汗、不肯进食,哭时有青紫,曾服利尿剂、地戈辛,病情无好转再次入院。体检:体温40.1℃,脉搏160,呼吸62,血压80/60,体重6公斤,发育营养差,神清,面部浮肿,烦躁,呼吸急促,多汗,唇周发绀,全身皮肤无出血点,浅表淋巴结未触及,胸廓对称,心尖搏动(氵弥)散,胸骨左缘第二肋间触及收缩期震颤,心界向左扩大,心律整,心率160次,胸骨左缘3、4肋间可闻及收 Medical records Yuan × ×, female, 10 months. 1 month due to edema, cough 1 week, fever 1 day, on October 26, 1979 second admission. Heart murmur was found in half a month after birth and diagnosed locally as congenital heart disease (congenital heart disease). Due to repeated fever in June 1979 for the first time to our hospital, the anti-infective, the general symptomatic treatment, hospitalization for 21 days. Diagnosis: 1. Congenital heart disease (patent ductus arteriosus and ventricular septal defect; 2. Pneumonia; 3. Summer fever, occasional cough after discharge, fever, edema. One month before admission, the whole body edema, oliguria , Irritability, sweating, refuse to eat, crying bruising, had diuretics, geoxin, the disease was no improvement again admitted to hospital Physical examination: body temperature 40.1 ℃, pulse 160, breath 62, blood pressure 80/60, weight 6 kg , Poor development of nutrition, clear facial, facial edema, irritability, shortness of breath, hyperhidrosis, cyanosis of the lips, no skin bleeding, superficial lymph nodes not touched, symmetrical thorax, apex beat Treating systolic tremor between the two intercostals, the heart bound to the left to expand, heart rhythm, heart rate 160 times, sternal left intercostal 3 can hear and receive