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病历摘要 女性,36岁,工人,住院号15007,因咳嗽3天伴气喘、发烧于1979年5月17日急诊入院。患者近1年常咳嗽,咯白色粘痰,曾按气管炎治疗。近1月上述症状加重,痰呈黄色,不易咳出,伴胸闷、气短、不能平卧,无咯血,门诊检查两肺有湿性罗音。3天来发热(体温38～39℃),食欲不振。摄胸部X线片示:两侧中部外带及两下肺片状阴影。患病后半年消瘦明显。既往有高血压史10年。
Medical record Summary Female, 36 years old, worker, hospital number 15007, cough 3 days with asthma, fever in May 17, 1979 emergency admission. The patient coughed nearly 1 year, slightly sticky phlegm, had treated by bronchitis. Nearly January the above symptoms, sputum yellow, difficult to cough, with chest tightness, shortness of breath, can not lie down, no hemoptysis, out-patient examination of both lungs have wet rales. 3 days to fever (body temperature 38 ~ 39 ℃), loss of appetite. Chest X-ray film shows: both sides of the outer band and two lung shadow. Half a year after illness weight loss significantly. Past history of hypertension for 10 years.