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病历摘要患者,女,48岁。1977年7月8日入院。住院号63202主诉:反复咳嗽三个月,畏冷,发热半个多月。现病史:1977年4月开始咳嗽。咳血,畏冷,发热,在当地保健院用链霉素,异菸肼,安络血等治疗好转,能参加劳动。6月中旬,以上腹闷痛、食减、嗳酸、腰酸痛、心悸,头昏,无力等就诊某地段医院,发现肝大、贫血,数天后畏冷、发热、咳嗽、气促,又就诊某部队医院发现心脏杂音、贫血。肝超声波检查:前2/3较密微小波偶见低波及中波,转我院。体检:体温38.5℃,脉搏96次/分,血压100/60毫米汞柱,神志清;皮肤无出血点,浅表淋巴结不
Patient history, female, 48 years old. July 8, 1977 admission. Inpatient number 63202 Chief complaint: repeated cough for three months, cold, fever half a month. Current medical history: April 1977 began to cough. Hemoptysis, Fear of cold, fever, streptomycin, isoniazid in the local health care hospitals, and other treatment of collateral circulation improved, to participate in labor. In mid-June, the above abdominal pain, food reduction, bezoar, back pain, palpitations, dizziness, weakness and other visits to a section of the hospital, found that liver, anemia, a few days after the cold, fever, cough, shortness of breath, and treatment A military hospital found heart murmur, anemia. Liver ultrasound: the first 2/3 of the more dense micro-wave occasionally low-wave and medium wave, turn our hospital. Physical examination: body temperature 38.5 ℃, pulse 96 beats / min, blood pressure 100/60 mm Hg, conscious; skin no bleeding point, superficial lymph nodes