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:normalCo-morbidconditions:Hypertension:AbsentCardiacdisease:AbsentDiabetesmellitus:AbsentKidneydisease:AbsentHistoryofinfectiousdiseases:Tuberculosis:AbsentHepatitis:AbsentOthers:29yearsago,hehadarenalhistoryoftuberculosis.Historyofpreventiveinoculation:Inoculationplancompleted.AllergicHistory:Historyofbloodtransfusion:Negative1.Drug:NegativeHistoryofscars/wounds:Negative2.Food:NegativeHistoryofsurgicaloperations:Negative3.Others:NegativeHistoryoflong-termdruguse:NegativeHistoryofdrugabuse: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:NegativeDrinkinghistory:Yes500ml/dayfor30yearsandstopped2yearsagoSmokinghistory:Yes20cigarettes/dayfor30yearsandstoppedfor2monthsToxin,dust,radioactiveorindustrialexposure:Negative婚姻、月经及生育史(Marital、MenstrualandChildbearinghistory):Maritalstatus:MarriedAgeofwedding:25yearsoldspouseheath:normalchildren:2sonsand1daughter;allhealthy家族史(FamilyHistory)：Father-deceasedCondition:unknownmother-deceasedCondition:unknownSiblings:HealthyHereditarydisease(s):NegativeCongenitaldisease(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°CWeight:notmeasuredkgHeight:notmeasuredcmPosture:Cananswercorrectlyandcollaborates.皮肤、黏膜(Skin、Mucosa)：Color:RefertospecialityRash:AbsentHemorrhage:AbsentEdema:refertospecialitySuperficiallymphnodes: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:N