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病历摘要 患者,男,52岁。因刺激性咳嗽伴发热一个半月于1982年8月7日入院。缘于1982年6月底开始低热,刺激性干咳,用青、链霉素治疗效果不佳。入院后每天午后畏寒,体温升高,最高达39℃,清晨降为37℃左右。伴有进行性呼吸困难,咳嗽,痰少。查体:急性病容,唇、指紫绀,呼吸加快,两肺呼吸音略增强,两腋下可闻及管状呼吸音及少许细水泡音。白细胞总数10,000左右,中性82～90％。血沉最快达90mm/第1小时。肝、肾功能正常。动脉血气分析:pH7.35～7.4;
Patient summary, male, 52 years old. Due to irritating cough with fever a month and a half on August 7, 1982 admission. Due to the end of June 1982 began fever, irritating dry cough, with green, streptomycin treatment ineffective. After admission every afternoon chills, body temperature, up to 39 ℃, early morning down to about 37 ℃. With progressive dyspnea, cough, phlegm. Physical examination: acute disease, lips, refers to cyanosis, breathing speed up, lung breath sounds slightly enhanced, the two armpits can smell tubular breath sounds and a few fine blisters sound. The total number of white blood cells around 10,000, 82% to 90% neutral. ESR up to 90mm / first hour. Liver, kidney function is normal. Arterial blood gas analysis: pH7.35 ~ 7.4;