-
大病例中英文对照
住院病历（一）
(Medical
Records for Admission)
入
院
记
录
(General Information for Hospital
Record)
姓
名
(Name)
：
邮
编
(Post
Code)
：
性
别
(S
ex)
：
MALE
< br>单位或现住址
（
Address)
：
年
龄
(Age)
：
56 years
old
身份证号
码
(
Identification No.)
：
婚
姻
(Marital
Status)
：
Married
户口地址
(Registered Residence
Address)
：
民
族
(R
ace)
：汉族
联系电话
(Contact Number):
出生地
(Place
of
Birth): FUDING
入院日期
(Date of
Admission)
：
2013-08-05
13:04:22
职
业
(Occupation):
病
史
陈
述
者
(Complainer of
History):
主诉
(Chief
Complaint)
：
headache
and
fever
for 10 days.
现病史
(History of the Present
Illness)
：
10
days
ago,
the
patient
had
headache
for
no
obvious reasons. There was persistent
pain
on the external parietal part of
the head.
The
pain
was
not
related
to
postural
changes.
The
trigger
was
unclear
but
was
accompanied
by
fever
with
body
temperature
fluctuations
between 38.5
°C
to
38.8
°C
. Moreover, the
patient
was
also
experiencing
dizziness,
nausea,
occasional
vomiting
of
stomach
contents.
There
is
no
blurred
vision,
tinnitus,
earache,
syncope,
numbness,
limbs
twitch, or
incontinence. He first went to
the
local
Fuding
hospital
where
they
performed
a
lumbar
puncture
on
him.
The
CSF
WBC
was
356X10^6/L,
monocytes
85%;
cerebrospinal
fluid
biochemistry:
chlorine
119
mmol/L,
glucose
1.74
mmol/L,
protein
1.79
mmol/L.
the
MRI
showed
“
bilateral
centrum
ovale
multiple
lacunar
lesions,
atherosclerotic
changes
in
white
matter,
chronic
sinusitis
”
. The patient was
then
diagnosed as
“
viral
meningitis
”
and was
prescribed
“
acycl
ovir
”
.
He
was
also
given
“
mannitol,
glycerol
&
fructose
injection
”
to
decrease
the
intracranial
pressure.
Furthermore, PPI was given to decrease
the
stomach pain and rehydration
treatment was
done
but,
there
was
no
significant
improvement
in
the
symptoms.
The
patient
then
came
to
the
emergency
room
of
our
hospital where he was
diagnosed as having
“
intracranial
infection
”
and
was
admitted
to
the
hospital.
Upon
admission,
the
patient
’
s mind
was clear, the spirit was
good, he had
a poor appetite, his sleep was
good,
he
had
soft
yellow
stool
and
there
was
no
significant change in weight. 29 years
ago,
the
patient
had
a
renal
history
of
tuberculosis.
住院病历（二）
(Medical Records for Admission)
既往史
(Past Medical
history)
：
General
health status: normal
Co-morbid
conditions:
Hypertension: Absent
Cardiac disease: Absent
Diabetes
mellitus: Absent Kidney disease: Absent
History of infectious diseases:
Tuberculosis: Absent Hepatitis:
Absent
Others:
29
years
ago,
he
had
a
renal
history
of tuberculosis.
History
Allergic
History
of
preventive
inoculation:
Inoculation
plan completed.
:
History of
blood
transfusion
: Negative
1.
Drug
:
Negative
History of
scars/wounds
: Negative
2.
Food
:
Negative
History of
surgical operations
: Negative
3.
Others
:
Negative
History of long-term drug
use
: Negative
History of
drug abuse
: Negative
系统回顾
(Review of
Systems)
：
?
HEENT:
No
hearing
loss,
tinnitus,
dizziness,
tooth
ache,
gingival
bleeding, throat
ache, hoarseness.
?
Respiratory
: no
chronic
cough,
sputum,
expectorant,
chest
pain,
asthma, dyspnea.
?
Cardiovascular:
No
increase
in
blood
pressure,
palpitation,
shortness
of
breath,
cyanosis,
precardial
pain,
orthopnea,
dizziness, lower limb edema.
?
GI:
No
hematemesis,
swallowing
difficulty,
abdominal
pain
or
distention, diarrhea, occult blood,
constipation, jaundice, rash
or
itching.
?
Genitourinary
system:
No
urinary
frequency,
urgency,
dysuria,
hematuria, pyuria,
nocturia or frothy urine.
?
Hemapoietic:
No
ecchymose,
purpura,
lymphadenopathy,
splenomegaly,
epistaxis or
gingival bleeding
?
Endocrine :no polydipsia, polyphagia,
polyuria,change in sexual
function or
personality or visual field defect.
?
Musculoskeletal:
No
dysarthria,
joint
abnormality,
spine
abnormality, muscle atrophy or weakness
in limbs.
?
Neurology: no headache, loss of memory,
aphasia, paralysis, tic.
?
Mental state: no hallucination,
delusional, disorientation, mood
disorder
个人史
(Personal
history)
：
Place
of
birth: Residence:
Epidemic
area:
None
Travel
history:
Negative
Drinking history: Yes 500ml/day for
30years and stopped 2 years ago
Smoking
history: Yes 20cigarettes/day for 30 years and
stopped for 2
months
Toxin,
dust, radioactive or industrial exposure:
Negative
婚姻
、
月经及生育史
(Marital
、
Menstrual and