英文--肝硬化完整大病历

1、 Complete Medical History General informationName: Du Donghe Sex: male Profession : retired worker Age:53 yearsNative place: Tian Jin Address:shenghe Department pujijian Road hebei district tianjinMarital state: married Nationality: Han Date of admission: July 16th 2012 Date of history taking :July

2、16th 2012Narrator: the patients daughter Reliability of the history: reliable The History Chief Complaint: weakness for 1 year, more severe with edema in lower limbs for half a year.Present Illness:1 years ago ,without significant causes,the patient began to feel weakness. No headache, dizzy, palpit

3、ation, shortness, abdominal pain or diarrhea . The patient went to the hospital in his town, and checked his live function, shown the live is damaged, given liver-protecting treatment(the detail of drugs used is unclear). But the symptom is not obviously lightened. And half a year ago ,the symptom b

4、ecame more severe,with edema in lower limbs , abdominal distension and bulge.No headache, dizzy, palpitation, shortness, tightness, abdominal pain or diarrhea . So the patient went to the out-patient department of our hospital to check the HBV-DNA 5.4 10E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).H

5、BsAb-IgG(+), PreS1(+). He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing. So he was accepted in our section for advanced diagnosis and treatment. Since the disease, no changes in consciousness, appetite, body we

6、ight .and normal of stool while less of urine. Past history: the patient became blind 50 years ago.And he has a history of hepatitis B for 26years. No history of chronic diseases like hypertension, CAD and mellitus diabetics. No tuberculosis .No history of trauma, operation and blood transfusion. He

7、 was allergic to penicillin and sulfa drugs.The history of vaccination is unclear.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: half a year age he had the edema at the lower limbs.no history of dysp

8、nea,palpitation or chest pain. No dizziness, headache.No history of hypertension.Digestive system: half a year age he began to have the abdominal distention and bulge.no history of anorexia, , regurgitation反流. No nausea and vomiting. No history of constipation , diarrhea ,melena .Urogenital system:

9、no history of swollen eyelids or lumbago腰疼. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: 1 years ago the patient began to feel weakness and became more severe ha

10、lf a year ago. No pallid 苍白countenance面容 ,dizziness , daze头昏眼花 ,tinnitus耳鸣. No history of bleeding and repeated infections.The MR scan shows splenomegaly.Metabolic and Endocrine system: no abnormal cold or hot feeling, hidrosis多汗 ,headache ,impaired vision,polyphagia 食欲过盛,polyuria ect.normal distrib

11、uted hair.no change of temper and intelligence.Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania躁狂 ,depression or hallucination.Motor system: No spasm, atrophy or palalysis. No joint red swollen, ho

12、t ,pain or limitation of motion. No trauma or fracture.Personal history : born in her native place and living in Tianjin. No history of exposure to radioactive poison.No habits of drinking or smoking.Marital History:. Married at 30 years old and having a son. his son and wife are both healthy.Family

13、 history: his mother had the hepatitis B.denying other family history of heredity diseases ,or MD, CAD, hypertension ect. Physical Examination Temperature: 37.1C pulse rate: 101/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no

14、abnormal consciousness, good corporation in examination. Free position. Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enla

15、rgement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine.Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . transpa

16、rent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos 眼球突出or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, No light reflexes, no accommodation and convergence reflexes. Vision , visual field

17、 and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good venti

18、lation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Tongue was in midline ,with normal in motion. No

19、redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils.Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of

20、 hepatojugular reflux.Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercos

21、tals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonan

22、ce in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10th on midclavicular ,midaxillary,midcapular line respectively in both left and right side. The movements of the lower margin of the lungs are 6 cm in both left and right side.Auscultation: rough of

23、vesicular breathing sounds all over the lung fields.fine rales are heard in bilateral subpulmonic parts.no rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm

24、in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill.Percussion: relative cardiac dullness shown as follows:Right (cm)ICS Left (cm)2224367 The distance between the left midclvicular line and the midsternal line is

25、 8cm.Auscultation: HR 101/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 101/min, with regular rhythm, equal in both sides, normal intensity .Perivascular signs: no capillary p

26、ulsation, water hammer pulse ,pistol-shot sounds and Duroziezs murmur . no pulse deficit, and pulse alternant. Abdomen:Inspection: symmetry. bulge abdomen .normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominal Skin.Palpation: tightened abdom

27、inal wall ,no tenderness and rebounding tenderness . No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphys sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters. Spleen: not palpable.Appendix: no tenderness at the Mcburneys site.Percussion: tym

28、pany in all over the abdomen, shifting dullness(+). No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular lineAuscultation: normal borhorygmus, 4/min, no murmur of vessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kypho

29、sis, or scoliosis. No tenderness and punching tenderness . No Limitation of movement. No changes in the local skin.Extremities: symmetry, no deformity . free motion .muscle strength is normal.no joint redness ,swollen ,tenderness or hotness. No acropachy,koilonychia,floating patella test(-).bilatera

30、l dorsalis pedis arteries can be palpated. edema in the lower extremities(+).Nerve system: Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal. knee jerk and Achilles jerk are also normal. babinskis ,oppenheims,chaddocks,gordons negative. Hoffmann sign (-). Neck tetany (-) Kernig si

31、gn (-).Brudzinski sign (-).No patellar or ankle clonus.Laboratory findings: HBsAg(+),HBsAb(+).HBsAb-IgG(+), PreS1(+). HBV-DNA 5.4 10E+4copies/ml,AFP13.91mg/ml(2012.6.29,GH)MRI : hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing.Summary The patient named Du Don

32、ghe ,male ,is 53years old,admission with the chief complaint of weakness for 1 year, more severe with edema in lower limbs for half a year in July 16th 2012 .1 years ago ,without significant causes,the patient began to feel weakness.He went to the hospital in his town, and checked his live function,

33、 shown the live is damaged, given liver-protecting treatment(the detail of drugs used is unclear). But the symptom is not obviously lightened. And half a year ago ,the symptom became more severe,with edema in lower limbs , abdominal distension and bulge.So the patient went to the out-patient department of our hospital to check the HBV-DNA 5.4 10E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+), PreS1(+). He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein rep