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:normalCo-morbid conditions:Hypertension:Absent Cardiac disease:AbsentDiabetes mellitus:Absent Kidney disease:AbsentHistory of infectious diseases:Tuberculosis:Absent Hepatitis:AbsentOthers:29years ago,he had a renal history of 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:Negative3.Others:NegativeHistory of long-term drug use:NegativeHistory 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 agoSmoking 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:unknownmother- deceased Condition:unknownSiblings:HealthyHereditary disease(s):NegativeCongenital disease(s):Negative in grandparents,parents or siblings.住院病历（三）(Medical Records for Admission)体格检查(Physical Examination)一般情况(General Appearance)Consciousness:Refer to speciality Pulse rate:78bpm Respiratory rate:20 times/min Blood pressure:128/70mmHg Temperature:38.8°CWeight:not measured kg Height:not measured cm Posture:Can answer correctly and collaborates.皮肤、黏膜(Skin、Mucosa)：Color:Refer to speciality Rash:Absent Hemorrhage:Absent Edema:refer to specialitySuperficial lymph nodes:No enlargement of superficial lymph nodes in the whole body头部及其器官(Head and HEENT)：Shape of head:Normal Conjunctiva:No hyperemia or edema Sclera:Refer to speciality Pupil:Symmetrically round Nasal cavity:Clear Sinus tenderness:Absent Teeth:Normal Oral mucosa:Normal Mastoid tenderness:Absent Hearing:No abnormality Tonsils:No enlargement Others:Negative颈部（Neck）:Flex:Soft position of trachea:Midline thyroid gland:No enlargement Jugular vein:No distension Others:None胸部(Chest)：Shape:Normal,symmetric intercostals space:Normal Breasts: Symmetric,no abnormality肺脏(Lungs)：Breathing:Symmetric percussion sound:Clear breath sounds:Clear Crackles:Absent Others:Absent心脏(Heart)：Heart rate:78bpm Heart sounds:Normal Murmurs:Absent Others:Absent血管(Blood Vessel)：Peripheral vessel sign:Negative腹部(Abdomen)：Refer to speciality外生殖器(Genitourinary system)：not examined直肠、肛门(Rectum、Anus)：Not examined四肢、脊柱(Extremities、Spine)：No abnormality神经系统(Neural System)：Muscle strength:Grade5Muscle tension:NormalKnee-jerk reflex:Normal Babinski’s sign;left:negative,right:negativeOthers:kernig(+)其他体征(Other Physical Signs)：Normal住院病历（四）(Medical Records for Admission)专科情况(Specific Appearance)：General condition:Dulled consciousness,NO left supraclavicular lymph node enlargement,no icterus,no lower limb edema,no palmar erythema,no spider telangiectasia,no skin pigmentation,no flapping tremor,no capillary distension,no fetor hepaticus.Abdomen:1.Inspection:External appearance:Smooth Abdominal vein distension:Absent Breathing type:hyperventilated Breathing movement:NormalSurgical scar:Absent Discoloration:Absent2.Palpation:No pain Pain with pressure or rebound tenderness:Absent Swelling:Absent Liver:Palpable Gall bladder:Absent,no pain with pressure,negative Murphy sign Spleen:Not palpable Kidney:Not palpable Bladder:Full(distended)3.Percussion:Dullness of border of liver:On right,mid-clavicular line on the5th ICS(Upper border)of a length of about9cm,no percussion pain on the region of the liver or gall bladder Dullness of border of spleen:Left mid-axillary line9-11th ICS,about9cm No shifting dullness,no percussion pain of the costophrenic region.4.Auscultation:Borborygmus:Normal No metallic sound5.Others:None特殊检查(Special Examination)：MRI:Intracranial CT scan shows no change,renal atrophy with multiple stones mainly in bladder, left ureter.There is gall bladder bile duct stone.There is pneumonia with bilateral pleural effusion.Bilateral centrum ovale multiple lacunar white matter changes in atherosclerotic lesions of chronic sinusitisLabs Data:2013/07/28Csf culture:protein+,wbc356*10^6/L,Monocyte85%,cl119mmol/l,Glucose 1.74mmol/L,protein1.79g/lCSF culture2013/07/31CSF:RBC18*10^6/L,WBC220*10^6/L,Monocyte:90%,CSF biochemistry:CL115mmol/L,Glucose1.91mmol/L,Protein1.68g/L,ADA:6U/L初步诊断(Primary Diagnosis):Intracranial infectionTuberculous meningitis。