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楚某某,女,11岁。住湘潭县双板桥乡。1987年5月14日就诊。祖母代诉:患儿发热、咳嗽、气促、右胸痛10余天,加重7天。于1987年4月14日收入湘潭县人民医院内科治疗,诊断为“胸腔积液、脓胸、结核性胸膜炎并感染。”经1个月抗感染、抗痨,对症支持疗法,胸腔抽液共1600毫升(5次),症状有所缓解,主治医师建议转省级医院诊治,患儿家属要求转我院中医治疗。现症:发热,咳嗽,气促,右胸痛,咳嗽时更甚,大便结,小便黄,神疲乏力,自汗,面色萎黄,舌苔黄腻,脉弦滑。查:体温38.5℃、脉搏110次
Chu Mou, female, 11 years old. Live in Shuangbanqiao Township, Xiangtan County. May 14, 1987 treatment. Grandmother’s complaint: fever, cough, shortness of breath, right chest pain for more than 10 days, an increase of 7 days. On April 14, 1987, he received medical treatment in the People’s Hospital of Xiangtan County and he was diagnosed with “Pleural effusion, empyema, tuberculous pleurisy and infection.” After 1 month of anti-infection, anti-convulsions, symptomatic supportive therapy, chest pumping 1600 ml (5 times), the symptoms have eased, the attending physician recommended that the transfer to the provincial hospital for treatment, the families of children with a request for transfer of Chinese medicine in our hospital. Current disease: fever, cough, shortness of breath, right chest pain, coughing, bowel movements, urine yellow, Shenpi fatigue, spontaneous perspiration, pale complexion, yellow greasy tongue coating, slippery pulse. Check: body temperature 38.5°C, pulse rate 110