论文部分内容阅读
病历摘要患者女性，25岁，住院号44597（重庆市第三人民医院）。因咳嗽一月余，加重伴发热、气急半月，于1978年3月7日入院。入院前一月余因受凉后咳嗽，多为干咳，未诊治。入院前半月不慎流产（5月孕），经当地医院治疗恶露止。自流产后即日起畏寒、发热、盗汗、咳嗽加剧，咯多量白色泡沫痰伴气急而来我院诊治，以支气管肺炎收入院。既往体健，有结核接触史，家族史无特殊。体检：体温38.4℃，脉搏120次/分，呼吸44次/分，血压10.4/6.7kPa（78/50mmHg）。呼吸急促，神清。全身皮肤、粘膜无皮疹，表浅淋巴结未触及。颈静脉充盈，双肺满布干、湿罗音。心率120次/分，无杂音，P_2＞A_2。肝肋下2cm，脾末扪及。
Patient Summary Female patient, 25 years old, hospital number 44597 (Chongqing Third People’s Hospital). More than a month due to cough, aggravated with fever, half-full of hysterical, on March 7, 1978 admission. One month before admission due to cold cough, mostly dry cough, not diagnosed. The first half of the hospital admitted to miscarriage (May pregnancy), the local hospital treatment of lochia. From the day after the abortion chills, fever, night sweats, increased cough, slightly more than a small amount of white foam phlegm with urgency came to our hospital for diagnosis and treatment, to bronchial pneumonia income hospital. Past physical health, a contact history of tuberculosis, family history no special. Physical examination: body temperature 38.4 ℃, pulse 120 beats / min, breathing 44 beats / min, blood pressure 10.4 / 6.7kPa (78 / 50mmHg). Shortness of breath, God clear. Whole body skin, mucous membrane without rash, superficial lymph nodes not touched. Jugular vein filling, lungs covered with dry rales. Heart rate 120 beats / min, no noise, P_2> A_2. Liver ribs 2cm, spleen end palpable.