大病例中英文对照

1、大病例中英文对照住院病历(一)(Medical Records for Admission)入院记录(General Information for Hospital Record)姓名(Name):邮编(PostCode):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(Pl

2、ace 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

3、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. T

4、here 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 356X10八6/L,monocytes 85%;cerebrospinal fluid biochemistry: chlorine 119 mmol/L, glucose 1.74 mmol/

5、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 ”

6、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 infe

7、ction 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） 既往史(Pas

8、t Medical history)General health status: normalCo-morbid conditions:Hypertension: Absent Cardiac disease: AbsentDiabetes mellitus: Absent Kidney disease: AbsentHistory of infectious diseases:Tuberculosis: Absent Hepatitis:AbsentOthers: 29 years ago, he had a renal history of tuberculosis.History of

9、preventive inoculation:Inoculation plan completed.Allergic History :History ofblood transfusion : Negative1. Drug:NegativeHistory of scars/wounds : Negative2. FoodNegativeHistory of surgical operations : Negative3. Others: NegativeHistory of long-term drug use : NegativeHistory of drug abuse : Negat

10、ive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, cyanos

11、is, 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

12、 urine.? Hemapoietic: Noecchymose, 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, spineabnormality, muscle atroph

13、y 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: NegativeDrinking history: Yes 500ml/day for 30year

14、s 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（MaritalMenstrual andChildbearing history):Marital status: Married Age of wedding: 25 years old spouse heath: normal children: 2 sons

15、and 1 daughter ; all healthy家族史(Family History):Father- deceased Condition: unknown mother- deceased Condition: unknown Siblings: HealthyHereditary disease(s): NegativeCongenital disease(s):Negative ingrandparents, parents or siblings.住院病历(三)(Medical Records for Admission)体格检查(Physical Examination)一

16、般情况(General Appearance)Consciousness : Refer to speciality Pulse rate : 78 bpmRespiratory rate :Temperature: 38.820 times/min Blood pressure : 128/70 mmHgWeight: not measured kgHeight : not measured cm Posture : Cananswer correctly and collaborates.皮肤、黏膜(Skin、Mucosa):Color: Refer to speciality Rash:

17、 Absent Hemorrhage: Absent Edem 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 Refer to specialityConjunctiva : No hyperemia or edemaPupil : Symmetrically roundSinus tenderness : Absent Mastoid ten

18、derness : Absent enlargement Others: Negative 颈部(Neck):Teeth: NormalNasal cavityOral mucosaHearing : No abnormalityFlex : Softposition of trachea : MidlineSclera:ClearNormalTonsils : Nothyroid glandNoenlargement Jugular vein:No distension Others: None胸部(Chest):Shape Normal, symmetric Symmetric, no a

19、bnormality 肺脏(Lungs): Breathing : Symmetric Clear Crackles : Absentintercostals space:Normal Breasts :percussion sound : Clear Others : Absentbreath sounds :心脏(Heart)Heart sounds : NormalMurmurs AbsentHeart rate : 78 bpm Others: Absent血管(Blood Vessel):Peripheral vessel sign : Negative腹部(Abdomen):Ref

20、er to speciality夕卜生殖器(Genitourinary system) : not examined直肠、月工门(Rectum、Anus): Not examinedSpine) : No四肢、 脊柱(Extremities abnormality神经系统(Neural System):Muscle strength : Grade 5 Muscle tension : NormalKnee-jerk reflex : Normal Babinski s sign ; left:negative, right: negativeOthers: kernig (+)其他体征(Ot

21、her 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

22、,no capillary distension,no fetor hepaticus.Abdomen:1. Inspection : External appearance: Smooth Abdominal vein distension:AbsentBreathing type:hyperventilatedBreathing movement: Normal Surgical scar: Absent Discoloration: Absent2. Palpation : No pain Pain with pressure or rebound tenderness: Absent

23、Swelling: Absent Liver: Palpable Gall bladder: Absent, no pain with pressure, negative Murphy signSpleen: Not palpableKidney: Not palpableBladder:Full(distended)3. Percussion : Dullness of border of liver: 一 ，.一一 thOn right, mid-clavicular line on the 5 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 percussi