大病例中英文对照.docx
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大病例中英文对照
大病例中英文对照
住院病历
（一）
（MedicalRecordsforAdmission）
入院记录
（GeneralInformationforHospitalRecord）
姓名（Name）：
邮编（PostCode）：
性别（Sex）：
MALE单位或现住址（Address）：
年龄（Age）：
56yearsold身份证号码（IdentificationNo.）：
婚姻（MaritalStatus）：
Married户口地址（RegisteredResidenceAddress）：
民族（Race）：
汉族联系电话（ContactNumber）:
出生地（PlaceofBirth）:
FUDING入院日期（DateofAdmission）：
2013-08-0513:
04:
22
职业（Occupation）:
病史陈述者（ComplainerofHistory）:
主诉（ChiefComplaint）：
headacheandfeverfor10days.
现病史（HistoryofthePresentIllness）：
10daysago,thepatienthadheadachefornoobviousreasons.Therewaspersistentpainontheexternalparietalpartofthehead.Thepainwasnotrelatedtoposturalchanges.Thetriggerwasunclearbutwasaccompaniedbyfeverwithbodytemperaturefluctuationsbetween38.5°Cto38.8°C.Moreover,thepatientwasalsoexperiencingdizziness,nausea,occasionalvomitingofstomachcontents.Thereisnoblurredvision,tinnitus,earache,syncope,numbness,limbstwitch,orincontinence.HefirstwenttothelocalFudinghospitalwheretheyperformedalumbarpunctureonhim.TheCSFWBCwas356X10^6/L,monocytes85%;cerebrospinalfluidbiochemistry:
chlorine119mmol/L,glucose1.74mmol/L,protein1.79mmol/L.theMRIshowed“bilateralcentrumovalemultiplelacunarlesions,atheroscleroticchangesinwhitematter,chronicsinusitis”.Thepatientwasthendiagnosedas“viralmeningitis”andwasprescribed“acyclovir”.Hewasalsogiven“mannitol,glycerol&fructoseinjection”todecreasetheintracranialpressure.Furthermore,PPIwasgiventodecreasethestomachpainandrehydrationtreatmentwasdonebut,therewasnosignificantimprovementinthesymptoms.Thepatientthencametotheemergencyroomofourhospitalwherehewasdiagnosedashaving“intracranialinfection”andwasadmittedtothehospital.Uponadmission,thepatient’smindwasclear,thespiritwasgood,hehadapoorappetite,hissleepwasgood,hehadsoftyellowstoolandtherewasnosignificantchangeinweight.29yearsago,thepatienthadarenalhistoryoftuberculosis.
住院病历
（二）
（MedicalRecordsforAdmission）
既往史（PastMedicalhistory）：
Generalhealthstatus:
normal
Co-morbidconditions:
Hypertension:
AbsentCardiacdisease:
Absent
Diabetesmellitus:
AbsentKidneydisease:
Absent
Historyofinfectiousdiseases:
Tuberculosis:
AbsentHepatitis:
Absent
Others:
29yearsago,hehadarenalhistoryoftuberculosis.
Historyofpreventiveinoculation:
Inoculationplancompleted.
AllergicHistory:
Historyofbloodtransfusion:
Negative
1.Drug:
NegativeHistoryofscars/wounds:
Negative
2.Food:
NegativeHistoryofsurgicaloperations:
Negative
3.Others:
Negative
Historyoflong-termdruguse:
Negative
Historyofdrugabuse:
Negative
系统回顾（ReviewofSystems）：
∙HEENT:
Nohearingloss,tinnitus,dizziness,toothache,gingivalbleeding,throatache,hoarseness.
∙Respiratory:
nochroniccough,sputum,expectorant,chestpain,asthma,dyspnea.
∙Cardiovascular:
Noincreaseinbloodpressure,palpitation,shortnessofbreath,cyanosis,precardialpain,orthopnea,dizziness,lowerlimbedema.
∙GI:
Nohematemesis,swallowingdifficulty,abdominalpainordistention,diarrhea,occultblood,constipation,jaundice,rashoritching.
∙Genitourinarysystem:
Nourinaryfrequency,urgency,dysuria,hematuria,pyuria,nocturiaorfrothyurine.
∙Hemapoietic:
Noecchymose,purpura,lymphadenopathy,splenomegaly,epistaxisorgingivalbleeding
∙Endocrine:
nopolydipsia,polyphagia,polyuria,changeinsexualfunctionorpersonalityorvisualfielddefect.
∙Musculoskeletal:
Nodysarthria,jointabnormality,spineabnormality,muscleatrophyorweaknessinlimbs.
∙Neurology:
noheadache,lossofmemory,aphasia,paralysis,tic.
∙Mentalstate:
nohallucination,delusional,disorientation,mooddisorder
个人史（Personalhistory）：
Placeofbirth:
Residence:
Epidemicarea:
NoneTravelhistory:
Negative
Drinkinghistory:
Yes500ml/dayfor30yearsandstopped2yearsago
Smokinghistory:
Yes20cigarettes/dayfor30yearsandstoppedfor2months
Toxin,dust,radioactiveorindustrialexposure:
Negative
婚姻、月经及生育史（Marital、MenstrualandChildbearinghistory）:
Maritalstatus:
MarriedAgeofwedding:
25yearsoldspouseheath:
normal
children:
2sonsand1daughter;allhealthy
家族史（FamilyHistory）：
Father-deceasedCondition:
unknown
mother-deceasedCondition:
unknown
Siblings:
Healthy
Hereditarydisease（s）:
Negative
Congenitaldisease（s）:
Negativeingrandparents,parentsorsiblings.
住院病历（三）
（MedicalRecordsforAdmission）
体格检查（PhysicalExamination）
一般情况（GeneralAppearance）
Consciousness:
RefertospecialityPulserate:
78bpmRespiratoryrate:
20times/minBloodpressure:
128/70mmHgTemperature:
38.8°C
Weight:
notmeasuredkgHeight:
notmeasuredcmPosture:
Cananswercorrectlyandcollaborates.
皮肤、黏膜（Skin、Mucosa）：
Color:
RefertospecialityRash:
AbsentHemorrhage:
AbsentEdema:
refertospeciality
Superficiallymphnodes:
Noenlargementofsuperficiallymphnodesinthewholebody
头部及其器官（HeadandHEENT）：
Shapeofhead:
NormalConjunctiva:
NohyperemiaoredemaSclera:
RefertospecialityPupil:
SymmetricallyroundNasalcavity:
ClearSinustenderness:
AbsentTeeth:
NormalOralmucosa:
NormalMastoidtenderness:
AbsentHearing:
NoabnormalityTonsils:
NoenlargementOthers:
Negative
颈部（Neck）:
Flex:
Softpositionoftrachea:
Midlinethyroidgland:
NoenlargementJugularvein:
NodistensionOthers:
None
胸部（Chest）：
Shape:
Normal,symmetricintercostalsspace:
NormalBreasts:
Symmetric,noabnormality
肺脏（Lungs）：
Breathing:
Symmetricpercussionsound:
Clearbreathsounds:
ClearCrackles:
AbsentOthers:
Absent
心脏（Heart）：
Heartrate:
78bpmHeartsounds:
NormalMurmurs:
AbsentOthers:
Absent
血管（BloodVessel）：
Peripheralvesselsign:
Negative
腹部（Abdomen）：
Refertospeciality
外生殖器（Genitourinarysystem）：
notexamined
直肠、肛门（Rectum、Anus）：
Notexamined
四肢、脊柱（Extremities、Spine）：
Noabnormality
神经系统（NeuralSystem）：
Musclestrength:
Grade5Muscletension:
Normal
Knee-jerkreflex:
NormalBabinski’ssign;left:
negative,right:
negative
Others:
kernig（+）
其他体征（OtherPhysicalSigns）：
Normal
住院病历（四）
（MedicalRecordsforAdmission）
专科情况（SpecificAppearance）：
Generalcondition:
Dulledconsciousness,NOleftsupraclavicularlymphnodeenlargement,noicterus,nolowerlimbedema,nopalmarerythema,nospidertelangiectasia,noskinpigmentation,noflappingtremor,nocapillarydistension,nofetorhepaticus.
Abdomen:
1.Inspection:
Externalappearance:
SmoothAbdominalveindistension:
AbsentBreathingtype:
hyperventilatedBreathingmovement:
Normal
Surgicalscar:
AbsentDiscoloration:
Absent
2.Palpation:
NopainPainwithpressureorreboundtenderness:
AbsentSwelling:
AbsentLiver:
PalpableGallbladder:
Absent,nopainwithpressure,negativeMurphysignSpleen:
NotpalpableKidney:
NotpalpableBladder:
Full（distended）
3.Percussion:
Dullnessofborderofliver:
Onright,mid-clavicularlineonthe5thICS（Upperborder）ofalengthofabout9cm,nopercussionpainontheregionoftheliverorgallbladderDullnessofborderofspleen:
Leftmid-axillaryline9-11thICS,about9cmNoshiftingdullness,nopercussionpainofthecostophrenicregion.
4.Auscultation:
Borborygmus:
NormalNometallicsound
5.Others:
None
特殊检查（SpecialExamination）：
MRI:
IntracranialCTscanshowsnochange,renalatrophywithmultiplestonesmainlyinbladder,leftureter.Thereisgallbladderbileductstone.Thereispneumoniawithbilateralpleuraleffusion.Bilateralcentrumovalemultiplelacunarwhitematterchangesinatheroscleroticlesionsofchronicsinusitis
LabsData:
2013/07/28Csfculture:
protein+,wbc356*10^6/L,Monocyte85%,cl119mmol/l,Glucose1.74mmol/L,protein1.79g/l
CSFculture
2013/07/31CSF:
RBC18*10^6/L,WBC220*10^6/L,Monocyte:
90%,
CSFbiochemistry:
CL115mmol/L,Glucose1.91mmol/L,Protein1.68g/L,ADA:
6U/L
初步诊断（PrimaryDiagnosis）:
Intracranialinfection
Tuberculousmeningitis
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