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病历摘要患者男性,46岁。因刺激性干咳2周,低热伴胸痛1周,于1981年1月13日入院。患者自1980年12月底开始刺激性干咳,1周后每天下午2点畏寒低热(37.6～38℃),继续干咳,服一般镇咳祛痰药并肌肉注射青霉素3天,未见效,遂入本院。体检:全身检查未发现阳性体征。化验检查:白细胞7,300,中性69%,血红蛋白10.3g,血沉43mm,肝功正常,痰内未找到抗酸杆菌。 X线检查:入院时胸片显示右肺下野片状阴影,密度欠均匀,边缘较模糊,两肺纹理略粗厚,双肺门阴影稍浓。
Medical record Summary Male patient, 46 years old. 2 weeks due to irritating dry cough, fever and chest pain for 1 week, January 13, 1981 admission. The patient started irritating cough at the end of December 1980, and chills and fever (37.6-38 ° C) at 2 pm every day after 1 week continued to dry cough, taking general antitussive and expectorant drugs and intramuscular injection of penicillin for 3 days, Our hospital. Physical examination: No physical examination found positive signs. Laboratory tests: white blood cells 7,300, 69% neutral, hemoglobin 10.3g, erythrocyte sedimentation rate 43mm, normal liver function, no acid-fast bacilli found in sputum. X-ray examination: admission chest radiograph showed flaky shadows, the density is less uniform, fuzzy edge, the lungs slightly thicker texture, slightly cloudy hilar double shadow.