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病历摘要:患者男,29岁。因左耳鸣伴听力下降2个月,兼右侧耳鸣、耳痛1周,于1985年5月25日入院.2个月前受凉起病,当地医院按卡他性中耳炎给青霉素、庆大霉素等不规则治疗2个月,服强地松月余.4天前出现发热、短阵胸痛、轻微干咳。查体:体温37.6℃,脉搏88次/分,呼吸20次/分,血压130/90mmHg。外耳道无分泌物,双耳鼓膜充血无穿孔,心肺腹无特殊发现。血常规:血红蛋白135g/L(13.5g/dl),白细胞10×10~9/L(10008/mm~2),中性65%,
Medical record summary: Patient male, 29 years old. Due to left ear tinnitus hearing loss for 2 months, and right side of the tinnitus, ear pain for 1 week, was admitted to hospital on May 25, 1985. 2 months ago onset of cold, local hospital by catarrhal otitis media to penicillin, Suffering from irregular treatment for 2 months, serving more than a month loose pine. 4 days ago fever, chest pain, mild dry cough. Examination: body temperature 37.6 ℃, pulse 88 beats / min, breathing 20 beats / min, blood pressure 130 / 90mmHg. No secretion of external auditory meatus, both ears eardrum congestion without perforation, no special cardiopulmonary abdominal findings. Blood: hemoglobin 135g / L (13.5g / dl), white blood cells 10 × 10 ~ 9 / L (10008 / mm ~ 2), neutral 65%