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病历摘要患者女,13岁,学生,因发热、进行性呼吸困难50余天,加重20天,于1976年6月26日急诊入院。患者50余天前始觉气急、发热,体温37～38℃,无胸痛、咳嗽。经中药治疗无好转。20天前,呼吸困难加重,在当地医院胸透为“肺炎”,经青,链霉素治疗无效。伴乏力、消瘦、纳差、轻咳,不能平卧,仍低热,咯少量白痰。既往无支气管炎及结核病史,身体健康。
Medical record Summary Female patient, 13 years old, student, due to fever, progressive dyspnea more than 50 days, increased 20 days, on June 26, 1976 emergency admission. More than 50 days before the patient began to feel irritable, fever, body temperature 37 ~ 38 ℃, no chest pain, cough. Chinese medicine treatment did not improve. 20 days ago, dyspnea worsened in the local hospital thoracic “pneumonia”, the green, streptomycin treatment ineffective. With fatigue, weight loss, anorexia, light cough, can not lie down, still low fever, slightly a little white sputum. No previous history of bronchitis and tuberculosis, good health.