原文：
主诉:体检发现左肺下叶占位1个月。
现病史: 患者1个月前在单位体检发现左肺结节影,建议患者到医院就诊,患者l周前到我院行CT检查示:左肺下叶背段支气管旁占位,考虑新生物可能大,患者偶有咳嗽咳痰,咳白色粘痰,无痰中带血,无寒战发热,无
气喘,无胸部疼疼痛,无乏力低热盗汗,无声音嘶哑,无吞咽困难,无肢体疼痛,无腹部疼痛等症状,今为求进一步诊治,特来我院就诊,门诊以“肺部占位”收治。
患者神志清,精神可,饮食睡眠良好,大小便无明显异常,体重近期无明显改变。
既往史: 平素身体健康,否认高血压史、否认糖尿病史、否认冠心病史否认输血史,否认药物、食物过敏史,预防接种史按计划进行,否认手术外伤史。
传染病史: 否认肝炎、结核、SARS、禽流感史及密切接触史。
个人生活史: 原籍出生,无外地久居史,无血吸虫病疫接触史,无地方病或传染病流行区居住史,无毒物、粉尘及放射性物质接触史,生活较规律,无吸烟史,无饮酒史,已婚结婚,配偶及子女体健,无冶游史。
家族史: 母亲有非霍其金淋巴瘤病史,否认家族遗传病史及类似疾病史。
译文：
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.