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1、UnionHospitalaffiliatedtoHuazhongUniversityofScienceandTechnologyAdmissionRecord0000337023Department:Respiratory MedicineArea:J17RespiratoryMedicineBedNo.109031CaseNo.1565825Name:HouDeguangGender:MaleDateofBirth:15/9/1936Age:78Nationality:ChinaIDNo.4201021936091
2、50819Ethnicity:HanOccupation:otherMaritalstatus:MarriedAddress:Nanchong,SichuanTelNo.13871426922SourceofHistory:PatientherselfReliability:ReliableAdmissionDate&Time:4/11/201414:36ChiefComplaint:Foundpleuraleffusionforabout2months.PresentIllness:Thepatientreceive
3、dthechestCTscanintheWuhanTraditionalMedicineHospitaltwomonthsagoandfoundright-sidepleuraleffusion,right-sidepulmonaryatelectasis.Afterthat,hewashospitalizedintheEndocrinologyDeptofourhospitalforpoormanagementofbloodglucoselevel.Onthisadmission,Hereceivedthethora
4、cocentesis,andthelaboratoryexaminationresultsindicatedthelargepossibilityoftuberculouspleuraleffusion.Nospecialtreatmentwasgivenatthattime.Thepatientwasawareofasenseofpolypneaafterlongwalk,withoutcough,expectoration,nightsweats,chestdistress,thoracalgia,wheeze,d
5、yspneaandcanliedowntosleepatnight.Thereturn-visitintheclinicatOctober13thshowedthattherewereafewpleuraleffusionontherightsideandishardtobelocalized.Nowthepatientcametoourhospitalforfurthertreatmentandwasadmittedas“Pleuraleffusionoriginunknown”.Sincetheonsetofthe
6、disease,thepatient’sspirit,appetiteandsleeparenormal.Nocturiafor1timepernight.Stoolareasusual.Noobviousweightandphysicalstrengthchange.PastHistory:GeneralHealthStatus:Relativelybad;RespiratorySystem:Chronicbronchitisforabout10years;CirculatorySystem:Hypertension
7、forabout20years,highestreached180/95mmHg,tookAmlodipineorally5mgqd,BPmanagementisgood.Diagnosedofcoronaryheartdiseasein2007,underwentintracoronary stent implantationin2008,3stentswereimplanted;DigestiveSystems:None;UrinarySystem:Benignprostatichyperplasiaforabou
8、t5years,Diabeticnephropathyfor3years;HematologicSystem:Thrombocytopeniafor2years;EndocrineSystem:None.NervousSystem: Lacunarinfarctionin2011;MotorSystem:None;Infectio