大病例中英文對照(已修改)
2024-10-04 00:02 本頁面
【正文】 住院病歷（一）(Medical Records for Admission) 入 院 記 錄(General Information for Hospital Record)姓 名(Name)： 郵 編(Post Code)： 性 別(Sex)：MALE 單位或現(xiàn)住址（Address)： 年 齡(Age)：56 years old 身份證號碼(Identification No.)：婚 姻(Marital Status)：Married 戶口地址(Registered Residence Address)： 民 族(Race)：漢族 聯(lián)系電話(Contact Number): 出生地(Place of Birth): FUDING 入院日期(Date of Admission)：20130805 13:04:22職 業(yè)(Occupation): 病史陳述者(Complainer of History): 主訴(Chief Complaint)： headache and fever for 10 days.現(xiàn)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 acpanied by fever with body temperature fluctuations between 176。C to 176。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 mmol/L, protein 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 amp。 fructose injection” to decrease the intracranial pressure. Furthermore, PPI was given to decrease the stomach pain and rehydration treat
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