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:normalCo-morbidconditions:Hypertension:AbsentCardiacdisease:AbsentDiabetesmellitus:AbsentKidneydisease:AbsentHistoryofinfectiousdiseases:Tuberculosis:AbsentHepatitis:AbsentOthers:29yearsago,hehadarenalhistoryoftuberculosis.HistoryofpreventiveInoculationplancompleted.AllergicHistory:inoculation:Historyofbloodtransfusion:Negative1.Drug:NegativeHistoryofscars/wounds:Negative2.Food:HistoryofsurgicaloperationsNegative: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,epistaxisorgingivalbleedingEndocrine: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:AbsentHemorrhageEdema:Absent:refertospecialitySuperficiallymphnodes:Noenlargementofsuperficiallymphnodesinthewholebody头部及其器官(HeadandHEENT)：Shapeofhead:NormalConjunctiva:NohyperemiaoredemaSclera:RefertospecialityPupil:SymmetricallyroundNasalcavity:ClearSinustenderness:AbsentTeeth:NormalOralmucosaNormal:Mastoidtenderness:AbsentHearing:NoabnormalityTonsils:NoenlargementOthers:Negative颈部（Neck）:Flex:Softenlargementpositionoftrachea:MidlineJugularvein:NodistensionOthers:Nonethyroidgland:No胸部(Chest)：Shapeintercostalsspace:NormalBreasts::Normal,symmetricSymmetric,noabnormality肺脏(Lungs)：Breathing:SymmetricClearCrackles:Absentpercussionsound:ClearOthers:Absentbreathsounds: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:NormalKnee-jerkreflex:NormalBabinski’ssign;left:negative,right:negativeOthers:kernig(+)其他体征(OtherPhysicalSigns)：Normal住院病历（四）(MedicalRecordsforAdmission)专科情况(SpecificAppearance)：Generalcondition:Dulledconsciousness,NOleftsupraclavicularlymphnodeenlargement,erythema,nospidertelangiectasia,noskinpigmentation,noflappingtremor,nocapillarydistension,nofetorhepaticus.Abdomen:Inspection:Externalappearance:SmoothAbdominalveindistension:AbsentBreathingtype:hyperventilatedBreathingmovement:NormalSurgicalscar:AbsentDiscoloration:Absent2.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:NormalNometallicsoundOthers:None特殊检查(SpecialExamination)：MRI:IntracranialCTscanshowsnochange,renalatrophywithmultiplestonesmainlyinbladder,leftureter.Thereisgallbladderbileductstone.Thereispneumoniawithbilateralpleuraleffusion.BilateralcentrumovalemultiplelacunarwhitematterchangesinatheroscleroticlesionsofchronicsinusitisLabsData:2013/07/28Csfculture:protein+,wbc356*10^6/L,Monocyte85%,cl119mmol/l,Glucose1.74mmol/L,protein1.79g/lCSFculture2013/07/31CSF: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):IntracranialinfectionTuberculousmeningitis