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患者,男,60岁,农民。因咳嗽,盗汗,乏力1个月,于2012年10月5日前往湖南省常德市某综合医院就诊。临床表现结合X线胸片诊断考虑为“肺结核”可能性大,于2012年11月1日转诊来我中心就诊。既往无结核病史、无结核病患者密切接触史和药物过敏史,其家族中亦无患过敏性疾病史。体格检查:神志清楚,发育中等,体温36.8℃,脉搏68次/min,呼吸频率20次/min,血压118/80mm Hg(1mm Hg=0.133kPa),体质量50kg。实验室及辅助检查,X线胸片显示:继发性肺结核,可能为双上肺;血红细胞沉降率14mm/1h,白细胞5.6×109/L,红细胞4.39×109/L,淋巴细胞0.287,血小板计数182×109/L,血红蛋白142g/L;
Patient, male, 60 years old, farmer. Due to cough, night sweats, fatigue 1 month, on October 5, 2012 to Changde City, Hunan Province, a general hospital for treatment. Clinical manifestations combined with the diagnosis of X-ray diagnosis of “pulmonary tuberculosis” is highly likely, referral to our center on November 1, 2012. Previous history of non-TB, non-TB patients with close contact history and drug allergy history, the family also had no history of allergic diseases. Physical examination: Conscious, moderately developed, body temperature 36.8 ℃, pulse 68 beats / min, respiratory rate 20 beats / min, blood pressure 118 / 80mm Hg (1mm Hg = 0.133kPa), body weight 50kg. Laboratory and auxiliary examination, X-ray showed: secondary pulmonary tuberculosis may be double on the lung; the rate of erythrocyte sedimentation 14mm / 1h, white blood cells 5.6 × 109 / L, red blood cells 4.39 × 109 / L, lymphocytes 0.287, Count 182 × 109 / L, hemoglobin 142g / L;