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赵××男70岁,住院号94009,以胸闷气短伴阴部胀疼十天为主诉入院。十天前因受凉后出现胸闷气短,心前区紧缩感,活动后加重,伴阴囊部持续性胀疼,尚能忍受。在家输青霉素、服消心痛等药物、效差。无腰疼,小便正常。既往冠心病史十年。查体:T 36.2℃ P 92次/分 BP 110/90mmHg。两肺呼吸音清。心律不齐,心音强弱不等,心脏各瓣膜未闻病理性杂音。腹软,肝脾未触及。双肾区无叩击痛。阴部无红肿,阴囊不肿大,无静脉曲张。心电图示:房颤,频发室性早搏,下壁陈旧性心肌梗塞。住院后,查腹
Zhao × × male, 70 years old, hospital number 94009, with chest tightness and shortness of breath with genitals pain ten days mainly admitted to hospital. Ten days ago due to chest tightness and shortness of breath after cold, precordial sense of tightness, aggravating after activity, with persistent swelling of the scrotum Department, still able to endure. Penicillin at home, taking heartache and other drugs, bad effect. No back pain, normal urine. Past history of coronary heart disease ten years. Examination: T 36.2 ℃ P 92 times / min BP 110 / 90mmHg. Breath sounds clear both lungs. Arrhythmia, heart sound intensity varies, the heart of the valve is not heard pathological murmur. Abdomen soft, liver and spleen not touched. Kidney zone percussion pain. No swelling genitals, scrotum is not swollen, no varicose veins. ECG shows: atrial fibrillation, frequent premature ventricular contractions, inferior myocardial infarction. After hospitalization, check the abdomen