大病例中英文对照

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1、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(Sex)：MALE 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(Race)：汉族 联系电话(Contact Number): 出生地(Plac

2、e 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 externa

3、l 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 38.5C to 38.8C. Moreover, the patient was also experiencing dizziness, nausea, occasional vomiting of stomach contents. There is

4、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 356X106/L, monocytes 85%; cerebrospinal fluid biochemistry: chlorine 119 mmol/L, glucose 1.74 mmol/L, prot

5、ein 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 “acyclovir”. He was also given “mannitol, glycerol & fructose injection” to decrease

6、 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

7、was admitted to the hospital. Upon admission, the patients 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 fo

8、r Admission) 既往史(Past Medical history)：General health status: normalCo-morbid conditions: Hypertension: Absent Cardiac disease: Absent Diabetes mellitus: Absent Kidney disease: AbsentHistory of infectious diseases:Tuberculosis: Absent Hepatitis: AbsentOthers: 29 years ago, he had a renal history of

9、tuberculosis.History of preventive inoculation: Inoculation plan completed.Allergic History: History of blood transfusion: Negative1.Drug: Negative History of scars/wounds: Negative2.Food: Negative History of surgical operations: Negative 3.Others: NegativeHistory of long-term drug use: NegativeHist

10、ory 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, short

11、ness 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

12、, 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 abnor

13、mality, 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 5

14、00ml/day for 30years and stopped 2 years agoSmoking history: Yes 20cigarettes/day for 30 years and stopped for 2 monthsToxin, dust, radioactive or industrial exposure: Negative婚姻、月经及生育史(Marital、Menstrual and Childbearing history):Marital status: Married Age of wedding: 25 years old spouse heath: nor

15、malchildren: 2 sons and 1 daughter ; all healthy家族史(Family History)：Father- deceased Condition: unknown mother- deceased Condition: unknown Siblings: HealthyHereditary disease(s): Negative Congenital disease(s): Negative in grandparents, parents or siblings. 住院病历（三）(Medical Records for Admission) 体

16、格 检 查(Physical Examination)一般情况(General Appearance)Consciousness: Refer to speciality Pulse rate: 78 bpm Respiratory rate: 20 times/min Blood pressure: 128/70 mmHg Temperature: 38.8C Weight: not measured kg Height: not measured cm Posture: Can answer correctly and collaborates. 皮肤、黏膜(Skin、Mucosa)：Co

17、lor: Refer to speciality Rash: Absent Hemorrhage: Absent Edema: refer to specialitySuperficial lymph nodes: No enlargement of superficial lymph nodes in the whole body头部及其器官(Head and HEENT)：Shape of head: Normal Conjunctiva: No hyperemia or edema Sclera: Refer to speciality Pupil: Symmetrically roun

18、d Nasal cavity: Clear Sinus tenderness: Absent Teeth: Normal Oral mucosa: Normal Mastoid tenderness: Absent Hearing: No abnormality Tonsils: No enlargement Others: Negative颈部（Neck）:Flex: Soft position of trachea: Midline thyroid gland: No enlargement Jugular vein: No distension Others: None 胸部(Chest

19、)：Shape: Normal, symmetric intercostals space: Normal Breasts: Symmetric, no abnormality 肺脏(Lungs)：Breathing: Symmetric percussion sound: Clear breath sounds: Clear Crackles: Absent Others: Absent 心脏(Heart)：Heart rate: 78 bpm Heart sounds: Normal Murmurs: Absent Others: Absent 血管(Blood Vessel)：Perip

20、heral vessel sign: Negative腹部(Abdomen)： Refer to speciality 外生殖器(Genitourinary system)：not examined直肠、肛门(Rectum、Anus)： Not examined四肢、脊柱(Extremities、Spine)：No abnormality 神经系统(Neural System)：Muscle strength: Grade 5 Muscle tension: Normal Knee-jerk reflex: Normal Babinskis sign; left:negative, right

21、: negative Others: kernig (+)其他体征(Other Physical Signs)：Normal住院病历（四）(Medical Records for Admission) 专科情况(Specific Appearance) ：General condition: Dulled consciousness, NO left supraclavicular lymph node enlargement, no icterus, no lower limb edema, no palmar erythema, no spider telangiectasia, no s

22、kin pigmentation, no flapping tremor,no capillary distension,no fetor hepaticus.Abdomen:1.Inspection: External appearance: Smooth Abdominal vein distension: Absent Breathing type: hyperventilated Breathing movement: NormalSurgical scar: Absent Discoloration: Absent2.Palpation: No pain Pain with pres

23、sure or rebound tenderness: Absent Swelling: Absent Liver: Palpable Gall bladder: Absent, no pain with pressure, negative Murphy sign Spleen: Not palpable Kidney: Not palpable Bladder: Full(distended)3.Percussion: Dullness of border of liver: On right, mid-clavicular line on the 5th ICS(Upper border

24、) of a length of about 9 cm , no percussion pain on the region of the liver or gall bladder Dullness of border of spleen: Left mid-axillary line 9-11th ICS, about 9 cm No shifting dullness, no percussion pain of the costophrenic region.4.Auscultation: Borborygmus: Normal No metallic sound5. Others:

25、None特殊检查(Special Examination)：MRI: Intracranial CT scan shows no change, renal atrophy with multiple stones mainly in bladder, left ureter. There is gall bladder bile duct stone. There is pneumonia with bilateral pleural effusion. Bilateral centrum ovale multiple lacunar white matter changes in athe

26、rosclerotic lesions of chronic sinusitisLabs Data:2013/07/28 Csf culture:protein+, wbc 356*106/L,Monocyte 85%,cl 119mmol/l,Glucose 1.74mmol/L, protein 1.79 g/lCSF culture2013/07/31 CSF: RBC18*106/L , WBC 220 *106/L , Monocyte: 90%, CSF biochemistry : CL 115mmol/L , Glucose 1.91 mmol/L, Protein 1.68g/L , ADA : 6U/L初步诊断(Primary Diagnosis):Intracranial infectionTuberculous meningitis 内容总结