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1、UnionHospitalaffiliatedtoHuazhongUniversityofScienceandTechnologyAdmissionRecord0000337023Department:Respiratory MedicineArea:J17RespiratoryMedicineBedNo.109031CaseNo.1565825Name:HouDeguangGender:MaleDateofBirth:15/9/1936Age:78Nationality:ChinaIDNo.4201021936
2、09150819Ethnicity:HanOccupation:otherMaritalstatus:MarriedAddress:Nanchong，SichuanTelNo.13871426922SourceofHistory:PatientherselfReliability:ReliableAdmissionDate&Time:4/11/201414:36ChiefComplaint:Foundpleuraleffusionforabout2months.PresentIllness:Thepatientr
3、eceivedthechestCTscanintheWuhanTraditionalMedicineHospitaltwomonthsagoandfoundright-sidepleuraleffusion,right-sidepulmonaryatelectasis.Afterthat,hewashospitalizedintheEndocrinologyDeptofourhospitalforpoormanagementofbloodglucoselevel.Onthisadmission,Hereceive
4、dthethoracocentesis,andthelaboratoryexaminationresultsindicatedthelargepossibilityoftuberculouspleuraleffusion.Nospecialtreatmentwasgivenatthattime.Thepatientwasawareofasenseofpolypneaafterlongwalk,withoutcough,expectoration,nightsweats,chestdistress,thoracal
5、gia,wheeze,dyspneaandcanliedowntosleepatnight.Thereturn-visitintheclinicatOctober13thshowedthattherewereafewpleuraleffusionontherightsideandishardtobelocalized.Nowthepatientcametoourhospitalforfurthertreatmentandwasadmittedas“Pleuraleffusionoriginunknown”.Sin
6、cetheonsetofthedisease,thepatient’sspirit,appetiteandsleeparenormal.Nocturiafor1timepernight.Stoolareasusual.Noobviousweightandphysicalstrengthchange.PastHistory:GeneralHealthStatus:Relativelybad;RespiratorySystem:Chronicbronchitisforabout10years;CirculatoryS
7、ystem:Hypertensionforabout20years,highestreached180/95mmHg,tookAmlodipineorally5mgqd,BPmanagementisgood.Diagnosedofcoronaryheartdiseasein2007,underwentintracoronary stent implantationin2008,3stentswereimplanted;DigestiveSystems:None;UrinarySystem:Benignprosta
8、tichyperplasiaforabout5years,Diabeticnephropathyfor3years;HematologicSystem:Thrombocytopeniafor2years;EndocrineSystem:None.NervousSystem: Lacunarinfarctionin2011;MotorSystem:None;Infectio
