论文部分内容阅读
患男,16岁,边远山区学生。因发热,胸痛,咳嗽12小时于1992年12月30日入院。12小时前开始发烧,寒战,右胸疼痛,阵发性咳嗽,初为干咳,后咯血丝痰,纳差。否认结核史。查:T 37℃,P 80次/分,BP 12/8kPa。营养中等,神志清,精神差,呼吸急促,皮肤、粘膜稍苍白,无皮疹,浅表淋巴结无肿大。口唇稍发绀,咽充血,扁桃体不大。颈软,气管居中。右下肺触觉语颤增强,叩呈浊音,呼吸音减弱,闻及细小湿罗音,心(一)。腹软稍胀,上腹偏右轻压痛,肝脾无肿大。血常规:Hb 85g/L,RBC 2.85×10~(12)/L,WBC 14.4×10~9/L,N 0.92,L 0.08;胸片示:右下大叶性肺炎。入院诊断:右下大叶性肺炎。予青霉素(960万μ/d),氨苄青霉素(5.0/d)及对症治疗6天,胸痛消失,咳嗽无明显减轻,咯暗红色血痰,纳差,乏力加重。
Male, 16 years old, remote mountain students. Due to fever, chest pain, cough for 12 hours on December 30, 1992 admission. 12 hours ago, fever, chills, right chest pain, paroxysmal cough, early as dry cough, hemoptysis sputum, anorexia. Denied the history of tuberculosis. Check: T 37 ℃, P 80 beats / min, BP 12 / 8kPa. Nutritious, conscious, poor spirit, shortness of breath, skin, mucous membrane slightly pale, no rash, superficial lymph nodes without swelling. Slightly cyanotic lips, pharyngeal congestion, little tonsils. Neck soft, tracheal center. Lower right lung tactile tremor increased, knocking was voiced, breath sounds weakened, smell and small wet rales, heart (a). Soft abdomen slightly inflamed, right lower abdomen soft tenderness, no swelling of the liver and spleen. Blood: Hb 85g / L, RBC 2.85 × 10-12 / L, WBC 14.4 × 10-9 / L, N 0.92, L 0.08; chest X-ray showed: right lower lobe pneumonia. Admission diagnosis: right lobar pneumonia. To penicillin (9.6 million μ / d), ampicillin (5.0 / d) and symptomatic treatment for 6 days, chest pain disappeared, no significant reduction in cough, slightly dark red bloody sputum, anorexia, fatigue worse.