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患者:李福生,男性,17岁,职业:工人,住院号:10200,太原市人,1959年11月14日入本院。主诉:咳嗽、胸痛、气短、周身无力感约一月之久。近五日来伴有盗汗、发热、腹泻、腹痛、头痛及身体瘦弱入院治疗。体征:发育正常,营养状态低下,意识清楚。头及颈部无异常,胸部除呼吸音弱外余均正常。腹部:肝不肿大,脾区触痛,有抵抗感,四肢及神经系均正常。化验:白血球120万,中性80％,淋巴球14％,血沉第一小时80mm。 X线检查:两肺野均显示大小均匀的粟粒形阴影,其它未见异常。诊断:急性粟粒型肺结核。
Patients: Li Fusheng, male, 17 years old, Occupation: worker, hospital number: 10200, Taiyuan city, November 14, 1959 into our hospital. Chief Complaint: Cough, chest pain, shortness of breath, whole body weakness about January. Nearly five days accompanied by night sweats, fever, diarrhea, abdominal pain, headache and poor body hospitalization. Signs: normal development, low nutritional status, clear awareness. No abnormality of the head and neck, the chest except the breath sounds are normal. Abdomen: liver enlargement, spleen tenderness, resistance, limbs and nervous system are normal. Laboratory tests: 1.2 million white blood cells, 80% neutral, 14% lymphocytes, ESR 80mm for the first hour. X-ray examination: both lung fields showed uniform size of the millet-shaped shadow, the other without exception. Diagnosis: Acute miliary tuberculosis.