大病例中英文對照

1、住院病歷（一）(Medical Records for Admission) 入 院 記 錄(General Information for Hospital Record)姓 名(Name)： 郵 編(Post Code)： 性 別(Sex)：MALE 單位或現(xiàn)住址（Address)： 年 齡(Age)：56 years old 身份證號碼(Identification No.)：婚 姻(Marital Status)：Married 戶口地址(Registered Residence Address)： 民 族(Race)：漢族 聯(lián)系電話(Contact Number): 誕生地(Plac

2、e of Birth): FUDING 入院日期(Date of Admission)：2013-08-05 13:04:22職 業(yè)(Occupation): 病史陳述者(Complainer of History): 主訴(Chief Complaint)： headache and fever for 10 days.現(xiàn)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 38.5°C to 38.8°C. Moreover, the patient was also experiencing dizziness, nausea, occasional vomiting of stomach content

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

5、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 “acyclovir”. He was also given “mannitol, glycerol & fructose inject

6、ion” 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

7、 infection” and 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.住院病歷（二）(Me

8、dical Records for 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 r

9、enal history of 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 u

10、se: NegativeHistory of drug abuse: Negative系統(tǒng)回顧(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

11、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

12、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.·

13、; 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個人史(Personal history)：Place of birth: Res

14、idence: Epidemic area: None Travel history: Negative Drinking history: Yes 500ml/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、月經(jīng)及生育史(Marital、Menstrual and Childbearing his

15、tory):Marital status: Married Age of wedding: 25 years old spouse heath: normalchildren: 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

16、grandparents, parents or siblings. 住院病歷（三）(Medical Records for Admission) 體 格 檢 查(Physical Examination)一般情況(General Appearance)Consciousness: Refer to speciality Pulse rate: 78 bpm Respiratory rate: 20 times/min Blood pressure: 128/70 mmHg Temperature: 38.8°C Weight: not measured kg Height: not

17、 measured cm Posture: Can answer correctly and collaborates. 皮膚、黏膜(Skin、Mucosa)：Color: Refer to speciality Rash: Absent Hemorrhage: Absent Edema: refer to specialitySuperficial lymph nodes: No enlargement of superficial lymph nodes in the whole body頭部及其器官(Head and HEENT)：Shape of head: Normal Conjun

18、ctiva: No hyperemia or edema Sclera: Refer to speciality Pupil: Symmetrically round Nasal cavity: Clear Sinus tenderness: Absent Teeth: Normal Oral mucosa: Normal Mastoid tenderness: Absent Hearing: No abnormality Tonsils: No enlargement Others: Negative頸部（Neck）:Flex: Soft position of trachea: Midli

19、ne thyroid gland: No enlargement Jugular vein: No distension Others: None 胸部(Chest)：Shape: Normal, symmetric intercostals space: Normal Breasts: Symmetric, no abnormality 肺臟(Lungs)：Breathing: Symmetric percussion sound: Clear breath sounds: Clear Crackles: Absent Others: Absent 心臟(Heart)：Heart rate:

20、 78 bpm Heart sounds: Normal Murmurs: Absent Others: Absent 血管(Blood Vessel)：Peripheral vessel sign: Negative腹部(Abdomen)： Refer to speciality 外生殖器(Genitourinary system)：not examined直腸、肛門(Rectum、Anus)： Not examined四肢、脊柱(Extremities、Spine)：No abnormality 神經(jīng)系統(tǒng)(Neural System)：Muscle strength: Grade 5 Mu

21、scle tension: Normal Knee-jerk reflex: Normal Babinskis sign; left:negative, right: negative Others: kernig (+)其他體征(Other Physical Signs)：Normal住院病歷（四）(Medical Records for Admission) ?？魄闆r(Specific Appearance) ：General condition: Dulled consciousness, NO left supraclavicular lymph node enlargement, n

22、o icterus, no lower limb edema, no palmar erythema, no spider telangiectasia, no skin 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: No

23、rmalSurgical scar: Absent Discoloration: Absent2.Palpation: No pain Pain with pressure 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) 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