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主治医师:请经治医师报告病历。经治医师:患者男,30岁。因突然畏寒、发热、咳嗽、偶有血痰3天。于1987年6月28日入院。一年前因工作不慎压伤胸部,右侧半身麻木,当时在当地卫生院检查无任何异常发现。1个月后咯血两口,又到当地卫生院检查仍无任何发现。以后常有全身不适,乏力、头晕,后来出现右胸疼痛,呼吸时明显。因咳嗽、发热、全身不适于1986年12月25日在当地卫生院住院治疗。当时体检:体温37.8℃,脉搏109次/分,血压120/80mmHg。
Attending Physician: Please report the medical record by the physician. By the physician: Patient male, 30 years old. Due to a sudden chills, fever, cough, bloody sputum occasionally 3 days. On June 28, 1987 admitted. A year ago due to work accidentally crushed the chest, the right side of the numbness, then check in the local hospital without any abnormal findings. 1 month hemoptysis after two, went to the local hospital still no discovery. Often after the general malaise, fatigue, dizziness, then right chest pain, breathing obvious. Due to cough, fever, general malaise December 25, 1986 in the local hospital for treatment. At that time physical examination: body temperature 37.8 ℃, pulse 109 beats / min, blood pressure 120 / 80mmHg.