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(Post Code)：

性别(Sex)：MALE单位或现住址（Address)：

年龄(Age)：56years 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(Place of Birth):FUDING入院日期(Date of Admission)：2013-08-0513:04:22

职业(Occupation):病史陈述者(Complainer of History):

主诉(Chief Complaint)：headache and fever for10days.

现病史(History of the Present Illness)：

10days 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

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:29years 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

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,cyanosis,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 urine.

•Hemapoietic:No ecchymose,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,spine abnormality,muscle atrophy 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:Negative Drinking history:Yes500ml/day for30years and stopped2years ago

Smoking history:Yes20cigarettes/day for30years and stopped for2months Toxin,dust,radioactive or industrial exposure:Negative

婚姻、月经及生育史(Marital、Menstrual and Childbearing history):

Marital status:Married Age of wedding:25years old spouse heath:normal children:2sons and1daughter;all healthy

家族史(Family History)：

Father- deceased Condition:unknown

mother- deceased Condition:unknown

Siblings:Healthy

Hereditary disease(s):Negative

Congenital disease(s):Negative in grandparents,parents or siblings.

住院病历（三）

(Medical Records for Admission)