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病历摘要朱××,男,69岁。患者于1975年5月出现发烧、胸部不适、胸痛、呼吸困难,曾先后两次在××医院住院,曾用青霉素、链霉素、雷米封、对氨基水杨酸钠等药物治疗,病情不见好转,逐渐加重,于1979年10月来我院住院治疗。查体:体温37.5℃,脉搏90次,呼吸26次,血压160/100毫米汞柱。神志清楚,消瘦,慢性病容,口唇无青紫,皮肤及粘膜无黄染、淋巴结无肿大,头颅正常,眼睑无浮肿,瞳孔等大等圆,咽部充血,扁桃体未肿大,无颈静脉怒张,胸廓右侧较饱满,语颤减弱。右侧胸部叩诊浊音,呼吸音减弱,心左界第五肋间左锁骨中线外1厘米,心尖区有Ⅰ级收缩期杂音。腹部平坦、肝脾未触及、无移动性浊音,肠鸣音正常。脊柱四肢正常。生理反射存在,未引出病理反射。右侧胸腔穿刺抽出黄白色液体。化验:白细胞
Medical record Zhu × ×, male, 69 years old. Patients in May 1975 fever, chest discomfort, chest pain, dyspnea, has twice been hospitalized in × × Hospital, who used penicillin, streptomycin, Remy, sodium salicylate and other drug treatment, the condition Not seen improvement, and gradually increased in October 1979 to our hospital for treatment. Physical examination: body temperature 37.5 ℃, pulse 90 times, breathing 26 times, blood pressure 160/100 mm Hg. Consciousness, weight loss, chronic disease, lips without bruising, skin and mucous membrane without yellow dye, lymph nodes without swelling, normal head, eyelid without swelling, pupils and other large round, throat congestion, tonsil enlargement, no jugular vein anger Zhang, right chest full, tremor weakened. The right chest percussion dullness, decreased breath sounds, the heart of the left intercostal left subclavian midline 1 cm, apex Ⅰ systolic murmur. Abdomen flat, liver and spleen not touched, no mobility dullness, bowel sounds normal. Spine limbs normal. Physiological reflex exists, did not lead to pathological reflex. Right pleural puncture out of yellow-white liquid. Laboratory: white blood cells