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患者李某,男,54岁,因发热、咳嗽、气促10天,于1990年2月10日步行入院,入院体查:T37.6℃(腋),一般情况尚可,神清合作。高级智能活动正常,呼吸稍促,双侧瞳孔等大等圆,对光反射灵敏,双肺呼吸音增粗,右肺闻及少量细湿罗音。心脏、腹部无异常,神经系统无病理征。既往体健,无肝炎、结核、精神异常及精神刺激史。家族中无精神病患者。实验资料:血常规Hb125g/L,WBC13.2×
Patient Lee, male, 54 years old, due to fever, cough, shortness of breath 10 days, walked on February 10, 1990 admission, admission physical examination: T37.6 ℃ (axillary), the general situation is acceptable, Shen Qing cooperation. Advanced intelligent activity is normal, breathing a little faster, bilateral pupil and other round, sensitive to light reflex, lung breath tone thickening, the right lung smell and a small amount of fine wet rales. Heart, abdomen without exception, the nervous system without pathological signs. Past physical health, no hepatitis, tuberculosis, mental disorders and mental stimulation history. No psychosis in the family. Experimental data: blood Hb125g / L, WBC13.2 ×