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1 病案摘要 患者男性,21岁,因刺激性咳嗽、胸闷、右胸痛20余天1994年10月2日入院。体检:T 36.2C,P 80次/min,R 18次/min,BP 16/10KPa。发育正常,营养—般,浅表淋巴结未扪及,心肺听诊无明显异常,肝脾未扪及,外生殖器查无异常。实验室检查:Hb 13.2g/dl,WBC 12.3×10~9/L、N 0.72、L0.28,肝肾功能、电解质检测均在正常范围。ECG:窦性心律不齐,心率68次/min,左心室高电压。
1 Medical Record Summary The patient was male, 21 years old, admitted to hospital on October 2, 1994 due to irritating cough, chest tightness, and right chest pain for more than 20 days. Physical examination: T 36.2C, P 80 beats/min, R 18 beats/min, BP 16/10 KPa. Normal development, nutrition-like, superficial lymph node is not affected, no abnormal heart and lung auscultation, liver and spleen is not affected, there is no abnormality in the external genitalia. Laboratory tests: Hb 13.2g/dl, WBC 12.3×10~9/L, N 0.72, L0.28, liver and kidney function, electrolyte detection were within the normal range. ECG: Sinus arrhythmia, heart rate 68 beats/min, left ventricular high voltage.