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病史摘要患者男,27岁,上海籍,住院号25480。因畏寒、发热,咳嗽4天,伴右侧胸痛、气急、咯血痰2天,于1983年2月27日入院。患者6天前感乏力,不适、咽痒,服土霉素。4天前起感畏寒、发热,体温38.3℃。咽痛、咳嗽,胸透示肺纹增深,用庆大霉素,安乃近等后体温未退。入院前8天胸透示两肺间质性肺炎,白细胞9000,中性85％,加用复方SMZ体温反升至39℃左右,并出现右侧胸痛,气急,痰夹杂鲜
Summary of patient history Male, 27 years old, Shanghai nationality, hospital number 25480. Because of chills, fever, cough for 4 days, with right chest pain, shortness of breath, hemoptysis sputum for 2 days, in February 27, 1983 admission. 6 days ago, patients with fatigue, discomfort, itchy throat, clothes oxytetracycline. Feeling chills and fever 4 days ago, body temperature 38.3 ℃. Sore throat, cough, chest X-ray showed deep lung enhancement, with gentamicin, analgin and other body temperature did not retreat. Eight days before admission chest showed interstitial pneumothorax of both lungs, 9000 white blood cells, neutral 85%, plus compound SMZ body temperature rose to about 39 ℃, and the right chest pain, shortness of breath, sputum mixed with fresh