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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)：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(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 diagnosed 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

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.