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病历摘要患者,辛×,男,67岁.病例号:64945.因慢性咳喘20余年加重1个月,于1991年4月21日入院.查体:T36,P120,R36,Bp20/12.神清语明,皮肤粘膜无出血点,浅表淋巴结无肿大,口唇及颜面重度发绀,桶状胸,肺肝界右锁骨中线第7肋间,双肺布满喘鸣音,左中下肺野可闻及小水泡音,心界不大,心率120次/分,律整,无杂音,腹软,肝右肋下2.0cm,质中等硬,无触痛,双下肢无浮肿.辅助检查:血常规:Hb120,RBC4.2×10~(12).WBC9×10~9.Sg0.64,Ly0.36,Pt130×
Patients with medical history, Xin ×, male, 67 years old. Case number: 64,945. Chronic cough and asthma exacerbated more than 20 years for 1 month, admitted to hospital on April 21, 1991. Examination: T36, P120, R36, Bp20 / 12. God clearly shows that the skin and mucous membrane without bleeding, superficial lymph nodes without swelling, lips and face severe cyanosis, barrel chest, lung and right subclavian midline 7 intercostal space, lungs covered with wheeze, left middle and lower lung Wild can smell and small blisters sound, heart, heart rate 120 beats / min, rhythm, no noise, abdominal soft, right ribs 2.0cm, medium hard, no tenderness, no swelling of both lower extremities. : Blood: Hb120, RBC4.2 × 10 ~ (12) .WBC9 × 10 ~ 9.Sg0.64, Ly0.36, Pt130 ×