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病历摘要女患,39岁。住院号125337。1982年2月始咳嗽、高热一周,住我油田结核病院,按肺结核正规抗痨治疗40多天未见好转,1983年5月赴省级医院就诊,多种检查未确诊,后据肺片诊断为“肺间质纤维化”,经抗生素及激素治疗2月,病情好转出院。入院前7个月咳嗽加重,咳白粘痰,盗汗,进行性呼吸困难,不规则发热,消瘦,于1984年5月4日入院,既往无慢支及风湿热病史。体检:体温39.7℃,消瘦,颜面部皮肤呈紫红色,表面有少许脱屑,呼吸浅快,两肺底有较多湿罗音,心率120次/分,心音低钝,四肢肌肉萎缩,杵状指,膝反
Female patient history, 39 years old. Hospital number 125337. In February 1982 the first cough, fever a week, live in the oilfield tuberculosis hospital, according to tuberculosis regular anti-tuberculosis treatment more than 40 days did not improve, in May 1983 went to the provincial hospital for treatment, a variety of tests were not diagnosed, after According to pulmonary diagnosis of “interstitial lung fibrosis”, by antibiotics and hormones in February, the condition improved and discharged. 7 months before admission, cough, cough, white phlegm, night sweats, progressive dyspnea, irregular fever, weight loss, admitted to hospital on May 4, 1984, without previous history of chronic bronchitis and rheumatic fever. Physical examination: Body temperature 39.7 ℃, weight loss, facial skin was purple, the surface a little scaling, breathing shallow fast, more lungs at the bottom of both rales, heart rate 120 beats / min, heart sound low blunt, limb muscle atrophy, clubbing Refers to the knee