大病例中英文对照
住院病历（一）
record是什么意思中文(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(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 diagnose
d 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

版权声明：本站内容均来自互联网，仅供演示用，请勿用于商业和其他非法用途。如果侵犯了您的权益请与我们联系QQ:729038198，我们将在24小时内删除。