原文：
主訴:體檢發(fā)現(xiàn)左肺下葉占位1個月。
現(xiàn)病史: 患者1個月前在單位體檢發(fā)現(xiàn)左肺結(jié)節(jié)影,建議患者到醫(yī)院就診,患者l周前到我院行CT檢查示:左肺下葉背段支氣管旁占位,考慮新生物可能大,患者偶有咳嗽咳痰,咳白色粘痰,無痰中帶血,無寒戰(zhàn)發(fā)熱,無
氣喘,無胸部疼疼痛,無乏力低熱盜汗,無聲音嘶啞,無吞咽困難,無肢體疼痛,無腹部疼痛等癥狀,今為求進(jìn)一步診治,特來我院就診,門診以肺部占位收治。
患者神志清,精神可,飲食睡眠良好,大小便無明顯異常,體重近期無明顯改變。

既往史: 平素身體健康,否認(rèn)高血壓史、否認(rèn)糖尿病史、否認(rèn)冠心病史否認(rèn)輸血史,否認(rèn)藥物、食物過敏史,預(yù)防接種史按計劃進(jìn)行,否認(rèn)手術(shù)外傷史。

傳染病史: 否認(rèn)肝炎、結(jié)核、SARS、禽流感史及密切接觸史。

個人生活史: 原籍出生,無外地久居史,無血吸蟲病疫接觸史,無地方病或傳染病流行區(qū)居住史,無毒物、粉塵及放射性物質(zhì)接觸史,生活較規(guī)律,無吸煙史,無飲酒史,已婚結(jié)婚,配偶及子女體健,無冶游史。

家族史: 母親有非霍其金淋巴瘤病史,否認(rèn)家族遺傳病史及類似疾病史。
 

譯文：

Chief complaint: A space-occupying lesion in inferior lobe of left lung for one month. 
History of present illness: The patient was diagnosed with a nodular shadow in the left lung one month ago. CT examination was carried out in our hospital one week before, which revealed a space-occupying lesion near the bronchus in the posterior segment of inferior lobe of left lung. On this basis, a neoplasm was suspected. The patient reported occasional cough and expectoration with white tenacious sputum. No blood was found in the sputum. No rigor, fever, chest distress, asthma or chest pain was noted. The patient reported no hypodynamia, low-grade fever, night-sweat, hoarseness or dysphagia. No limb pain or abdominal pain was present. The patient presented to outpatient with a space-occupying lesion in lung for further treatment. 
The patient was conscious with satisfactory mental status. His diet and sleep were satisfactory. No abnormality was identified in the defection and urination. The patient reported no obvious weight changes. 

Past history:

The patient was in a healthy status. He denied histories of hypertension, coronary heart disease and blood transfusion. The patient denied history of drug or food allergy. The prophylactic immunization was performed as planned. No history of surgery and wound was reported. 

The history of communicable diseases: 

The patient denied histories of hepatitis, tuberculosis, SARS, bird flu. Also, he denied the exposure of these diseases. 

Personal history: 

The patient was born in his native place. He reported no history of exposure to schistosomiasis. The patient denied the history of living in the native disease area or infected area. Also, the patient denied the history of exposure to poisoning, dust and radioactive substances. He reported regular life habbits. No history of smoking or alcohol was reported. His spouse and children are in a good health.