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患者(李某,住院号6903)男性,45岁于1963年10月7日入院。主诉咳嗽、咯血6个月。起病时诊断为肺结核,用异菸肼治疗,症状一度好转。入院前1个月症状加重,无发热或盜汗,不感乏力,体重未减。既往无慢性咳嗽及吐痰史,曾吸烟多年。入院时体格检查:发育营养尚好。体温37.4℃。呼吸、脉搏及血压均正常。右颌下可触及两个淋巴结。气管居中。右下胸叩诊稍浊,呼吸音略低,双肺散在干
Patient (Lee, hospital number 6903) male, 45 years old, was admitted to hospital on October 7, 1963. Chief complaint cough, hemoptysis 6 months. Diagnosis of pulmonary tuberculosis onset, with isoniazid treatment, the symptoms once improved. 1 month before admission symptoms increased, no fever or night sweats, do not feel fatigue, weight is not reduced. No previous history of chronic cough and spitting, smoking for many years. Physical examination on admission: Developmental nutrition is still good. Body temperature 37.4 ℃. Breath, pulse and blood pressure are normal. Right mandible palpable two lymph nodes. Tracheal center. Right lower chest percussion slightly turbid, breath sounds slightly lower, lungs scattered dry