住院病歷（一）(MedicalRecordsforAdmission)入院記錄(GeneralInformationforHospitalRecord)姓名(Name)：郵編(PostCode)：性別(Sex)：MALE單位或現(xiàn)住址（Address)：年齡(Age)：56yearsold身份證號碼(IdentificationNo.)：婚姻(MaritalStatus)：Married戶口地址(RegisteredResidenceAddress)：民族(Race)：漢族聯(lián)系電話(ContactNumber):出生地(PlaceofBirth):FUDING入院日期(DateofAdmission)：2013-08-0513:04:22職業(yè)(Occupation):病史陳述者(ComplainerofHistory):主訴(ChiefComplaint)：headacheandfeverfor10days.現(xiàn)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.住院病歷（二）(MedicalRecordsforAdmission)既往史(PastMedicalhistory)：Generalhealthstatus:normalCo-morbidconditions:

Hypertension:AbsentCardiacdisease:AbsentDiabetesmellitus:AbsentKidneydisease:Absent

Historyofinfectiousdiseases:

Tuberculosis:AbsentHepatitis:Absent

Others:29yearsago,hehadarenalhistoryoftuberculosis.

Historyofpreventiveinoculation:Inoculationplancompleted.

AllergicHistory:Historyofbloodtransfusion:Negative

1.Drug:NegativeHistoryofscars/wounds:Negative

2.Food:NegativeHistoryofsurgicaloperations:Negative

3.Others:Negative

Historyoflong-termdruguse:Negative

Historyofdrugabuse:Negative

系統(tǒng)回顧(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.4.Auscultation:Borborygmus:NormalNometallicsound

5.Others:None特殊檢查(SpecialExamination)：MRI:IntracranialCTscanshowsnochange,renalatrophywithmultiplestonesmainlyinbladder,leftureter.Thereisgallbladderbileductstone.Thereispneumoniawithbilateralpleuraleffusion.BilateralcentrumovalemultiplelacunarwhitematterchangesinatheroscleroticlesionsofchronicsinusitisLabsData:2013/07/28Csfculture:protein+,wbc356*10^6/L,Monocyte85%,cl119mmol/l,Glucose1.74mmol/L,protein1.79g/lCSFculture