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1病例摘要患者女,50岁,会计。因“咳嗽、咳痰1个月余,胸痛半天”于2011-11-26入院。缘于1个多月前无明显诱因出现阵发性咳嗽,偶于咳嗽后出现喘鸣,约2 min可自行缓解:较多白色粘液痰,无异味:曾有痰痂咳出,用水冲洗后发现如树枝状。中药治疗无好转,至我院内科门诊,胸部CT平扫:右肺上叶前段小片状密度增高影。按“肺炎”予“头孢替胺”抗感染、对症治疗6 d,症状好转:停药1 d后症状加重,昨夜出现右胸持续性钝痛,咳嗽时加重,遂收入院。起病以来,无发热、盗汗,胃纳、二便正常,体重无减轻。出生、居住于顺德,无食鱼生等生食史。既往体健。入院查体:体温37.1℃,脉搏76次/min,呼吸18次/min,血压121/74 mmHg(1 mmHg=0.133 kPa)。意识清,无皮下结节,全身浅表淋巴结无肿大。胸廓无畸形,呼吸运动对称,触觉语颤对称,双肺叩诊清音,双肺呼吸音粗,未闻及干、湿啰音和胸膜摩擦音。心界不大,心率76次/min,律齐,未闻及杂音。腹部无压痛及肿块,肝脾肋下未触及。病理反射未引出。
1 Case Summary Female patient, 50 years old, accounting. Because “cough, sputum more than 1 month, chest pain for a long time ” in 2011-11-26 admission. Due to more than a month ago no obvious incentive to paroxysmal cough, occasionally cough after wheezing, about 2 min to ease: more white mucus sputum, no smell: had phlegm scab, washed with water Found as dendritic. Chinese medicine treatment did not improve, to our hospital outpatient clinic, chest CT scan: right upper lobe of the anterior small patchy density increased shadow. According to “pneumonia” to “cefotiam” anti-infection, symptomatic treatment of 6 d, the symptoms improved: withdrawal of symptoms after 1 d, last night there was dull right chest dull pain, increased cough, then admitted to hospital. Since onset, no fever, night sweats, appetite, two will be normal, no weight loss. Born, living in Shunde, no food raw fish and other raw food history. Past physical health. Admission examination: body temperature 37.1 ℃, pulse 76 beats / min, breathing 18 beats / min, blood pressure 121/74 mmHg (1 mmHg = 0.133 kPa). Clear consciousness, no subcutaneous nodules, systemic superficial lymph nodes without swelling. Thoracic deformity, symmetrical respiratory movement, tactile tremor symmetry, lung percussion voiceless, breath sounds coarse lungs, did not smell and dry, wet rales and pleural friction sound. Heart, heart rate 76 times / min, law Qi, did not smell and noise. Abdominal tenderness and lumps, liver and spleen ribs did not touch. Pathological reflex did not lead.