大病例中英文对照.docx

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(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 “acyclovir”. 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 of preventive inoculation: Inoculation plan completed.
Allergic History: 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 Childbearing history):
Marital status: Married Age of wedding: 25 years old spouse heath: normal
children: 2 sons and 1 daughter ; all healthy

家族史(Family History)：
Father- deceased Condition: unknown
mother- deceased Condition: unknown
Siblings: Healthy
Hereditary disease(s): Negative
Congenital disease(s): Negative in grandparents, parents or siblings.

住院病历（三）
(Medical Records for Admission)

体 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: 38.8°C
Weight: not measured kg Height: not measured cm Posture: Can answer correctly and collaborates.

皮肤、黏膜(Skin、Mucosa)：
Color: Refer to speciality Rash: Absent Hemorrhage: Absent Edema: refer to speciality
Superficial 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 round 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)：
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)：
Peripheral 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 Babinski’s sign; left:negative, right: 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 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: Normal
Surgical scar: Absent Discoloration: Absent

2.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 pain of the costophrenic region.

4.Auscultation: Borborygmus: Normal No metallic sound
5. Others: 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 atherosclerotic lesions of chronic sinusitis

Labs Data:

2013/07/28 Csf culture:protein+, wbc 356*10^6/L,Monocyte 85%,cl 119mmol/l,Glucose 1.74mmol/L, protein 1.79 g/l
CSF culture

2013/07/31 CSF: RBC18*10^6/L , WBC 220 *10^6/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 infection

Tuberculous meningitis