over skin．Superficial lymph nodes were not enlarged．Skull and head organs were normal and there was no jaundice on sclerae．The neck could move freely and thyroid glands were not engorged．Chest was symmetrica1．Tactile fremitus exaggerated slightly over the right upper chest and a lot of small and moderate moist rales were heard．Heart beats were normal without any noise．Abdomen was flat and soft and free from tenderness．Liver and spleen could not be palpated．Bowel sounds were norma1．There was no abnorma1ity in spine or limbs．Knee jerks of both sides were active．There were no pathological reflexes．

       Routine blood test：RBC 4 500 000／mm3，Hb 14．5g％,WBC 21 000／mm3，N 8O％ ，L 19％ ，E 1％．

       Platelet count：150000／mm3．

       Chest fluoroscopy：there was a big patchy shadow over upper right lung．

       译文2

       Admission Note

       A 30-year-old married female was admitted to the hospital on August 3，1996，because of a 7．day fever and cough．

       Seven days ago，she began running a fever and having a bad cough productive of mucous sputum，for which she has not taken any medical treatment up to now．In the past three days，she has been having a persistent high fever，an exacerbated cough productive of rusty sputum and a thoracalgia intensified with respirations．

       During her illness，she has been weak and has had a poor appetite without specific urine or stools．She has been in good health and has seldom consulted physicians in the past．

       There is no tuberculosis in her family medical history and she does not know of any intimate exposure to patients with this disease either．

       PE T ：39c； P：107／min．R：26／min．：BP= 110／70 mmHg．

       Well developed, poorly nourished．Acutely ill-looking，still mentally dear．No cyanosis．No eruption or purpura over skin．Superficial lymph nodes not palpable．Skull an head organs not abnorma1．No jaundice on sclerae．Neck soft and supple．Thyroid not enlarged．Trachea not deviated．No engorgement of jugular veins. Chest not asymmetrica1． Tactile fremitus exaggerated slightly over the right upper chest and a lost of small and moderate moist rales heard here．Heart beat regular with no murmur．Abdomen flat，soft and free from tenderness．Liver and spleen impalpable．Intestinal peristaltic sounds not abnorma1．No abnormality detected in spine or limbs．Knee jerks of b

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