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病历摘要男,30岁,农民,1977年5月25日入院,住院号77-1438。病者于4月28日开始高热,寒颤,咳嗽,右侧胸痛,继而咳出大量脓臭痰,经当地卫生院住院治疗,应用多种抗菌素,症状继续加重,并出现呼吸急促,遂转来我院。一般情况较差,呼吸38次/分,脉搏88～140次/分,体温38～40℃,血压110/78毫米汞柱,气管稍左移,心脏无特殊,右肺叩诊浊实,右肺呼吸音减弱,两肺有干湿罗音。右上腹腹肌紧张,肝在肋下三指,有压痛,脾未触及。无病理神经反射。 X线胸部检查:右侧液气胸。
Medical summary Male, 30 years old, farmer, admitted on May 25, 1977, hospital number 77-1438. Patients began fever, shivering, cough, right chest pain on April 28, and then coughing a lot of pus phlegm, hospitalized by the local hospitals, the application of a variety of antibiotics, the symptoms continue to aggravate, and the shortness of breath, then turn to Our hospital. Generally poor, breathing 38 beats / min, pulse 88 ~ 140 beats / min, body temperature 38 ~ 40 ℃, blood pressure 110/78 mm Hg, trachea slightly left, no special heart, right lung percussion turbid real right lung Breath sounds weakened, both lungs have wet and dry rales. Right upper quadrant abdominal tension, liver in the ribs three fingers, tenderness, spleen not touched. No pathological nerve reflex. Chest X-ray examination: right liquid pneumothorax.