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,epistaxisorgingivalbleedingEndocrine:nopolydipsia,polyphagia,polyuria,changeinsexualfunctionorpersonalityorvisualfielddefect.Musculoskeletal:Nodysarthria,jointabnormality,spineabnormality,muscleatrophyorweaknessinlimbs.Neurology:noheadache,lossofmemory,aphasi...