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患者男,33岁,上海籍,机修工,住院号158755。1981年4月初因干咳、畏寒、高热两月,在外院拟诊为肺炎。用庆大、红及氯霉素治疗一周,体温曾降至37.8℃,但仍有刺激性咳嗽,并伴进行性胸闷、气急。一周后体温又升至38℃以上,气急更甚。痰培养普通细菌和真菌均阴性。经用青霉素等多种抗生素治疗,病情无改善。于1981年6月6日住入我院。十年前有上消化道出血发作一次,经胃肠钡餐检查诊断为十二指肠球部溃疡。不吸烟。 入院体检:神志清,消瘦,体温38℃,脉搏120次/分,呼吸30次/分,血压130/70 mmHg。气急明显,尚能平卧,活动后有紫绀。气管居中,胸廓对称,两肺有广泛哮鸣音及少量湿啰音。心率快,心脏未见其他异常。腹软,肝脾未扪及,无杵状指,前列腺检查无异常。
The patient was male, 33 years old, of Shanghai nationality, a mechanic, hospital number 158755. In the early April 1981 due to dry cough, chills, and high fever for two months, he was diagnosed with pneumonia in an external hospital. After one week of treatment with Qingda, red and chloramphenicol, the body temperature had dropped to 37.8°C, but there was still irritating cough with progressive chest tightness and shortness of breath. After one week, the body temperature rose above 38°C, and the urgency increased. Sputum culture common bacteria and fungi were negative. After treatment with penicillin and other antibiotics, the condition did not improve. He was admitted to our hospital on June 6, 1981. Tens of years ago there was an episode of upper gastrointestinal bleeding, and a duodenal ulcer was diagnosed by gastrointestinal barium examination. do not smoke. Admission examination: clear mind, weight loss, body temperature 38 °C, pulse 120 beats / min, breathing 30 beats / min, blood pressure 130/70 mmHg. The urgency is obvious, and it is still able to lie flat. After the activity, there is a purpura. The trachea is centered and the thorax is symmetrical. There are extensive wheezes and a few wet rales in both lungs. The heart rate is fast and the heart has no other abnormalities. The abdomen is soft, the liver and spleen are not palpable, and there is no abnormality in the prostate examination.