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病历摘要杨××,男,42岁,住院号:61513。因干咳、胸痛、进行性呼吸困难2年,加重2周,发热2天,于1989年6月18日入院。该患于2年前开始,无诱因干咳、气短、胸部闷痛,逐渐出现呼吸困难,并进行性加重,半年前开始夜间不能平卧。无发热,盗汗、咯血。曾在本院及本市、北京等大医院诊治,最初用糖皮质激素治疗约一个月,自觉好转;用抗生素、抗结核药、中药治疗均无效、病情逐渐加重。既往20年前患肺结核,
Medical records Yang × ×, male, 42 years old, hospital number: 61513. Due to dry cough, chest pain, progressive dyspnea 2 years, increased 2 weeks, fever 2 days, on June 18, 1989 admission. The suffering from 2 years ago, no incentive to dry cough, shortness of breath, chest pain, gradually breathing difficulties, and progressive increase, six months ago, the night can not lie down. No fever, night sweats, hemoptysis. In this hospital and the city, Beijing and other large hospitals for treatment, initially treated with glucocorticoid for about a month, conscientiously improved; with antibiotics, anti-TB drugs, traditional Chinese medicine treatment were ineffective, the condition gradually aggravated. Pulmonary tuberculosis in the past 20 years ago,