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1、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(Plac
2、e 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 externa
3、l 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 38.5C to 38.8C. Moreover, the patient was also experiencing dizziness, nausea, occasional vomiting of stomach contents. There is
4、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 356X106/L, monocytes 85%; cerebrospinal fluid biochemistry: chlorine 119 mmol/L, glucose 1.74 mmol/L, prot
5、ein 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
6、 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
7、was admitted to the hospital. Upon admission, the patients 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 fo
8、r Admission) 既往史(Past Medical history)：General health status: normalCo-morbid conditions: Hypertension: Absent Cardiac disease: Absent Diabetes mellitus: Absent Kidney disease: AbsentHistory of infectious diseases:Tuberculosis: Absent Hepatitis: AbsentOthers: 29 years ago, he had a renal history of
9、tuberculosis.History of preventive inoculation: Inoculation plan completed.Allergic History: History of blood transfusion: Negative1.Drug: Negative History of scars/wounds: Negative2.Food: Negative History of surgical operations: Negative 3.Others: NegativeHistory of long-term drug use: NegativeHist
10、ory 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, short
11、ness 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
12、, 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 abnor
13、mality, 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: Yes 5
14、00ml/day for 30years and stopped 2 years agoSmoking history: Yes 20cigarettes/day for 30 years and stopped for 2 monthsToxin, 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: 25 years old spouse heath: normalchildren: 2 sons and 1 daughter ; all healthy家族史(Family History)：Father- deceased Condition: unknown mother- deceased Condition: unknown Siblings: HealthyHereditary disease(s): Negative Congenital disease(s): Negative in grandparents, parents or siblings.
