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病历摘要患者男性,58岁。因左侧胸闷、气短10天,于1990年6月25日住院。患者于入院前10天无诱因渐感胸闷、气短,活动后加重,伴左臂、左胸隐痛。无咳嗽、咳痰和咯血,无发热、盗汗。纳差,尿少黄,每日约600ml。在厂医院作 B 超示左侧胸腔积液。既往身体健康,无石棉接触史。吸烟20余年,20支/d。入院查体体温37.4℃,脉搏86次,呼吸32次,血压20.0/12.0kPa。肥胖,神志清楚。左腋窝触及蚕豆大淋巴结1个,可活动,质地中,无压痛。口唇紫绀,气管右偏,左肺叩诊呈实音,呼吸
Medical record summary The patient was 58 years old. He was hospitalized on June 25, 1990 due to left chest tightness and shortness of breath for 10 days. The patient had no feelings of sensation of chest tightness, shortness of breath, and aggravation after 10 days before admission, with pain in his left arm and left chest. No cough, sputum, and hemoptysis, no fever, night sweats. Anorexia, less yellow urine, about 600ml daily. The B-ultrasound showed left pleural effusion at the factory hospital. Past health, history of non-asbestos exposure. Smoking for more than 20 years, 20/d. The admission body temperature was 37.4°C, the pulse was 86, the breath was 32, and the blood pressure was 20.0/12.0 kPa. Obesity, conscious. The left armpit touches one of the broad bean lymph nodes, which is active and free of tenderness in texture. Purple cyanosis, right tracheal deviation, left lung palpation, real sound, breathing