英文肝硬化完整大病历Word格式.docx

英文肝硬化完整大病历Word格式.docx

《英文肝硬化完整大病历Word格式.docx》由会员分享，可在线阅读，更多相关《英文肝硬化完整大病历Word格式.docx（5页珍藏版）》请在冰豆网上搜索。

retiredworkerAge:

53years

Nativeplace:

TianJinAddress:

shengheDepartmentpujijianRoadhebeidistricttianjin

Maritalstate:

marriedNationality:

Han

Dateofadmission:

July16th2012Dateofhistorytaking:

July16th2012

Narrator:

thepatient'

sdaughterReliabilityofthehistory:

reliable

TheHistory

Chiefplaint:

weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.

PresentIllness:

1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainordiarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment（thedetailofdrugsusedisunclear）.Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoresevere,withedemainlowerlimbs,abdominaldistensionandbulge.Noheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml,AFP13.91mg/ml,HBsAg（+）,HBsAb（+）.HBsAb-IgG（+）,PreS1（+）.HealsohadaMRscanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvanceddiagnosisandtreatment.Sincethedisease,nochangesinconsciousness

appetite,bodyweight.andnormalofstoolwhilelessofurine.

Pasthistory:

thepatientbecameblind50yearsago.AndhehasahistoryofhepatitisBfor26years.Nohistoryofchronicdiseaseslikehypertension,CADandmellitusdiabetics.Notuberculosis.Nohistoryoftrauma,operationandbloodtransfusion.Hewasallergictopenicillinandsulfadrugs.Thehistoryofvaccinationisunclear.

ReviewofSystems:

Respiratorysystem:

nohistoryofchroniccough,expectoration,hemoptysis,chestpain,orshortofbreath.

Circulationsystem:

halfayearagehehadtheedemaatthelowerlimbs.nohistoryofdyspnea,palpitationorchestpain.Nodizziness,headache.Nohistoryofhypertension.

Digestivesystem:

halfayearagehebegantohavetheabdominaldistentionandbulge.nohistoryofanorexia,,regurgitation反流.Nonauseaandvomiting.Nohistoryofconstipation,diarrhea,melena.

Urogenitalsystem:

nohistoryofswolleneyelidsorlumbago腰疼.Nofrequentmicturition,urgencyofmicturitionorurodynia.Nodysuria,hematuriaorretentionandincontinenceofurine.nohistoryofacuteorchronicnephritis.

Hemopoelticsystem:

1yearsagothepatientbegantofeelweaknessandbecamemoreseverehalfayearago.Nopallid苍白countenance面容,dizziness,daze头昏眼花,tinnitus耳鸣.Nohistoryofbleedingandrepeatedinfections.TheMRscanshowssplenomegaly.

.

MetabolicandEndocrinesystem:

noabnormalcoldorhotfeeling,hidrosis多汗,headache,impairedvision,polyphagia食欲过盛,polyuriaect.normaldistributedhair.nochangeoftemperandintelligence.

Nervoussystem:

Noheadache,projectilevomiting.nosyncope,spasm,impairedvision,abnormalsensationormotion.Nochangeofpersonality.nomania躁狂,depressionorhallucination.

Motorsystem:

Nospasm,atrophyorpalalysis.Nojointredswollen,hot,painorlimitationofmotion.Notraumaorfracture.

Personalhistory:

borninhernativeplaceandlivinginTianjin.Nohistoryofexposuretoradioactivepoison.Nohabitsofdrinkingorsmoking.

MaritalHistory:

.Marriedat30yearsoldandhavingason.hissonandwifearebothhealthy.

Familyhistory:

hismotherhadthehepatitisB.denyingotherfamilyhistoryofhereditydiseases,orMD,CAD,hypertensionect.

PhysicalExamination

Temperature:

3Cpulserate:

101/minrespiratoryrate:

18/minbloodpressure:

130/80mmHg

Generalappearance:

normaldevelopmentandmediuminnourished,noabnormalconsciousness,goodcorporationinexamination.Freeposition.

Skinandmucousmembrane:

Nopallid,cyanosis,andjaundice.noabnormalpigmentationanddepigmentation.noerythmaannulare,petechiaandspiderangioma.Normalelasticityofskin,noedema.

Superficiallymphnodes:

noenlargementofthesuperficiallymphnodes.

Headanditsorgans:

Skull:

nodeformity,tendernessormass.Evenlydistributedhairwithblackcolorandshine.

Eyes:

nodropoutofeyebrowandnomadarosis,noswollenorprolapseofeyelids.Nopallor,granules,folliclespectechiaeofconjunctivae.transparentofcornea,nonebula,keratoleukoma,malacia,ulcerorvascularization.Noexophthalmos眼球突出orenophthalmos.freemotionsoftheeyeballsinanydirection.Equalandroundpupilsatbothsideswithdiameter4mm,Nolightreflexes,noacmodationandconvergencereflexes.Vision,visualfieldandeyegroudnotexamined.

Ears:

nodeformity.noabnormalsecretionfromexternalcanals.Nored,tenderness,swolleninthemastoid.Roughtested