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1、UnionHospitalaffiliatedtoHuazhongUniversityofScienceandTechnologyAdmissionRecordDepartment:Respiratory MedicineArea:J17RespiratoryMedicineBedNo.CaseNo.Name:HouDeguangGender:MaleDateofBirth:15/9/1936Age:78Nationality:ChinaIDNo.Ethnicity:HanOccupation:otherMaritalst
2、atus:MarriedAddress:Nanchong，SichuanTelNo.SourceofHistory:PatientherselfReliability:ReliableAdmissionDate&Time:4/11/201414:36ChiefComplaint:Foundpleuraleffusionforabout2months.PresentIllness:ThepatientreceivedthechestCTscanintheWuhanTraditionalMedicineHospitaltwom
3、onthsagoandfoundright-sidepleuraleffusion,right-sidepulmonaryatelectasis.Afterthat,hewashospitalizedintheEndocrinologyDeptofourhospitalforpoormanagementofbloodglucoselevel.Onthisadmission,Hereceivedthethoracocentesis,andthelaboratoryexaminationresultsindicatedthel
4、argepossibilityoftuberculouspleuraleffusion.Nospecialtreatmentwasgivenatthattime.Thepatientwasawareofasenseofpolypneaafterlongwalk,withoutcough,expectoration,nightsweats,chestdistress,thoracalgia,wheeze,dyspneaandcanliedowntosleepatnight.Thereturn-visitintheclinic
5、atOctober13thshowedthattherewereafewpleuraleffusionontherightsideandishardtobelocalized.Nowthepatientcametoourhospitalforfurthertreatmentandwasadmittedas“Pleuraleffusionoriginunknown”.Sincetheonsetofthedisease,thepatient’sspirit,appetiteandsleeparenormal.Nocturiaf
6、or1timepernight.Stoolareasusual.Noobviousweightandphysicalstrengthchange.PastHistory:GeneralHealthStatus:Relativelybad;RespiratorySystem:Chronicbronchitisforabout10years;CirculatorySystem:Hypertensionforabout20years,highestreached180/95mmHg,tookAmlodipineorally5mg
7、qd,BPmanagementisgood.Diagnosedofcoronaryheartdiseasein2007,underwentintracoronary stent implantationin2008,3stentswereimplanted;DigestiveSystems:None;UrinarySystem:Benignprostatichyperplasiaforabout5years,Diabeticnephropathyfor3years;HematologicSystem:Thrombocyto
8、peniafor2years;EndocrineSystem:None.NervousSystem: Lacunarinfarctionin2011;MotorSystem:None;InfectionHistory:NoinfectionofhepatitisandTB.Others:Nonespec
