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患者男,61岁。因咳嗽、咳痰伴活动后胸闷、气喘15 d入院。患者入院15 d前受凉后出现咳嗽、咳痰,呈阵发性,伴有活动后胸闷、气喘,病初有发热,曾自服青霉素V钾片、头孢类抗生素,体温控制,但咳喘无改善。入院查体:神志清楚,右侧胸廓饱满,右侧触觉语颤减低,叩诊右下肺呈浊音,听诊两肺呼吸音粗,右下肺呼吸音减低,可闻及散在干湿性啰音。
Male patient, 61 years old. Due to cough, sputum with chest tightness after activity, asthma 15 d admission. Patients were admitted to hospital 15 days before the onset of cold cough, expectoration, paroxysmal, chest tightness after activity, asthma, early fever, had penicillin V potassium tablets, cephalosporins antibiotics, body temperature control, but no cough and asthma improve. Admission examination: Consciousness, full right thorax, the right tactile vocal tremor reduced, percussion right lower lung was voiced, auscultation of the lungs coarse breath sounds, lower right lung breath sounds reduced, can be heard and scattered wet and dry rales.