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一、病史摘要 住院号:38707,男,62岁,某酒厂制曲工。1984年5月22日入院。患者10余年来经常咳嗽、咳痰,以冬春季症状明显,早晨及睡眠前咳嗽加剧,痰呈白色粘稠样,不易咳出,痰中无脓血。发病时伴有胸闷气急。曾在基层医院拟“慢支”给予治疗,症状略有改善。经胸透、摄片提示左下肺有空洞阴影。近三月来咳嗽、咳痰加剧,病后常伴头昏,无头痛、发热、畏寒、盗汗及咯血等现象。无明显消瘦,食欲正常。查体:轻度桶状胸,左肺呼吸音增粗,干性啰音。痰涂片见少量炎症细胞。血常规,肺功能等项目检查均无异常。过去史:1968年曾患肺结核,经服用异菸肼等药一年余“治愈”,以后来用过抗结核药物。无心、肝、肾疾患。个人史:1964～1983年间断续有吸烟史,5～7支/日,黄酒0.5市斤/日。
First, a summary of history Hospital number: 38707, male, 62 years old, a brewery system Qu Gong. May 22, 1984 admission. Patients with more than 10 years often cough, sputum, obvious symptoms of winter and spring, cough before going to sleep in the morning and increased, sputum was viscous white, easy to cough, no sputum sputum blood. When accompanied by chest tightness and angina. In the primary hospital proposed “chronic bronchitis” to give treatment, the symptoms improved slightly. Transcranial, radiography prompted the left lower lobe shadow. Nearly three months to cough, exacerbated sputum, sickness often accompanied by dizziness, no headache, fever, chills, night sweats and hemoptysis and so on. No significant weight loss, normal appetite. Physical examination: mild barrel chest, left lung breath tone thick, dry rales. See a small amount of sputum smear inflammatory cells. Blood tests, pulmonary function tests without exception. Past history: In 1968, I had tuberculosis. After taking isoniazid and other drugs for more than a year, I cured it and used anti-tuberculosis drugs later. No heart, liver, kidney disease. Personal history: 1964 ~ 1983 intermittent smoking history, 5 to 7 / day, rice wine 0.5 kg / day.