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病历摘要患者女性,28岁,农民,住院号141797,1981年12月10日17时急诊入院。半年前(妊娠3月)出现颜面、下肢浮肿,渐及全身。经当地医院治疗,浮肿减轻。1周前浮肿加重,伴咳嗽、咯血,日咯血5—6次,约200ml,暗红色,不与痰混。3日来咳嗽剧,心慌、气短,夜难平卧,咯血逐日增多,急来我院。患者平素体健,无可述之心肺病史,能胜任重体力劳动。月经史正常,入院时为1胎0产9月妊娠。入院体检T36.8℃,P100次,R25次,BP110/80。神志清,半卧位,急重病容,轻度贫血貌。颧赤唇柑,颈静脉怒张。两侧胸
Medical records Summary Female patient, 28 years old, farmer, hospital number 141797, December 10, 1981 emergency at admission. Six months ago (pregnancy March) appear facial, lower extremity edema, gradually and the whole body. After local hospital treatment, edema reduced. A week ago, edema increased, with cough, hemoptysis, hemoptysis 5-6 times, about 200ml, dark red, not mixed with sputum. 3 days to cough drama, palpitation, shortness of breath, difficulty lying at night, hemoptysis increased daily, anxious to our hospital. Patients usually no health, no history of heart and lung disease, capable of heavy manual labor. Menstrual history is normal, admission to 1 fetus 0 September pregnancy. Admission physical examination T36.8 ℃, P100 times, R25 times, BP110 / 80. Conscious, semi-recumbent, critically ill, mild anemia appearance. Zygomatic red lips orange, jugular vein engorgement. Chest on both sides