英文肝硬化完整大病历Word文档格式.docx
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英文肝硬化完整大病历Word文档格式.docx
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weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.
PresentIllness:
1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainordiarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoreseverewithedemainlowerlimbs,abdominaldistensionandbulgeNoheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-lgG(+),PreS1(+).HealsohadaMRscanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvaneeddiagnosisandtreatment.Sineethedisease,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countenanc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.nochangeoftemperandintelligenee.
Nervoussystem:
Noheadache,projectilevomiting.nosyncope,spasmimpairedvision,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:
37.1Cpulserate:
101/minrespiratoryrate:
18/minbloodpressure:
130/80mmHg
Generalappearanee:
normaldevelopmentandmediuminnourished,noabnormalconsciousness,goodcorporationinexamination.Freeposition.
Skinandmucousmembrane:
Nopallid,cyanosis,andjaundice.noabnormalpigmentationanddepigmentation.noerythmaannulare,petechiaandspiderangioma.Normalelasticityofskir,noedemaSuperficiallymphnodes:
noenlargementofthesuperficiallymphnodes.
Headanditsorgans:
Skull:
nodeformity,tendernessormass.Evenlydistributedhairwithblackcolorandshine.
Eyes:
nodropoutofeyebrowandnomadarosis,noswollenorprolapseofeyelids.Nopallor,granules,folliclespectechiaeofconjunctivae.transparentofcornea,nonebula,keratoleukoma,malacia,ulcerorvascularization.Noexophthalmos眼球突出orenophthalmosfreemotionsoftheeyeballsinanydirection.Equalandroundpupilsatbothsideswithdiameter4mm,Nolightreflexes,noaccommodationandconvergeneereflexes.Vision,visualfieldandeyegroudnotexamined.
Ears:
nodeformity.noabnormalsecretionfromexternalcanals.Nored,tenderness,swolleninthemastoid.Roughtestednormalhearing.
Nose:
nodeformity.Nodeviationofseptumnasi.Noalaflutter.Noedema,abnormalsecretion,andcongestionofthemembrane.goodventilation.Notendernessinanyparanasalsinuses.
Buccalcavity:
nopallidorcyanosisoflips,alsonodryness,herpessimplex.Nocongestion,petechiaorulcerinthebuccalmembrane.32teeth,nocaries.Nobleedingorcongestion,leadlineingums.Tonguewasinmidline,withnormalinmotion.Norednessandcongestioninpharynx,nodeviationofuvulae.Noedemaintonsils.
Neck:
symmetry.noenlargementofexternaljugularvein,noabnormalpulsationofcarotidarteriesorveins.Norigidity.noenlargementofthyroidglands,andthetracheainthecenteralposition.Nomurmur.Negativeofhepatojugularreflux.
Chest:
symmetry.Nodeformity.Nobarrelchest,pigeonchestorfunnelchest.Notendernessoverthechest.thethoracicrespirationpresent.R18/min,symmetryinbothsides.Symmetryandnoabnormalityofthe2breasts.
Lungs:
Inspections:
nobulgesorrecessionoftheintercostalsspacesduringrespiration.Respiratorymovementequalinbothsidesandregular.nodyspneaorthreeconcavesign.
Palpation:
symmetryrespiratorymovementinthetwosides,noincreaseordecreaseofvocalfremitus.Nopleuralfrictionfremitus.nosubcutaneouscrepitation.
Percussion:
resonanceinalloverthelungfields.5cminwidthofapexes,andthelowermarginoflungat6th,8th,10thonmidclavicular,midaxillary,midcapularlinerespectivelyinbothleftandrightside.Themovementsofthelowermarginofthelungsare6cminbothleft
andrightside.
Auscultation:
roughofvesicularbreathingsoundsalloverthelungfields.fineralesareheardinbilateralsubpulmonicpartsnorhonchis.normalofvocalresonance.Nopleuralfrictionsound.
Heart:
Inspection:
noprecordialbulging.Apicalimpulseinthe5thICS1cminsideofleftmidclavicularlinewithanareaof2cmindiameter.
apicalimpulseanditsareaasthatininspection.Regular,normalintensity.Nopericardialfrictionrubsorthrill.
relativecardiacdullnessshownasfollows:
Right(cm)
ICS
Left(cm)
2
n
皿
4
3
IV
6
V
7
Thedistancebetweentheleftmidclvicularlineandthemidsternallineis
8cm.
HR101/minwithregularrhythm,heartsoundsclearandintensive.nomurmursatanyauscultationareaofthevalvula.Nopericardicalfrictionsound.
Radialarteries:
pulserate101/min,withregularrhythm,equalinbothsides,normalintensity.
Perivascularsigns:
nocapillarypulsation,waterhammerpulse,pistol-shotsoundsandDuroziez'
smurmur.nopulsedeficit,andpulsealternant.Abdomen:
Inspection:
symmetry.bulgeabdomen.normalabdominalrespiration.Novisiblegastrointestinalwaves.Novaricosity,scar,petechiaattheabdominalSkin.
tightenedabdominalwall,notendernessandreboundingtenderness.Nopalpablemass.
Liver:
notpalpable.
Gallbladder:
notpalpable.Negativeofmurphy'
ssign.
Kidneys:
notpalpable.Notendernessintheanysiteofkidneysorureters.
Spleen:
Appendix:
notendernessattheMcburney'
ssite.
tympanyinallovertheabdomen,shiftingdullness(+).Nopercussivepainofliverandspleen.Theuppermarginofliveratthe5thICSintherightmidcalvicularlineAuscultation:
normalborhorygmus,4/min,nomurmurofvessels.Nofrictionrubs.
Anusandrectum:
notexamined.
Spine:
nolordosis,kyphosis,orscoliosis.Notendernessandpunchingtenderness.NoLimitationofmovement.Nochangesinthelocalskin.
Extremities:
symmetry,nodeformity.freemotion.musclestrengthisnormal.nojointredness,swollen,tendernessorhotness.Noacropachy,koilonychia,floatingpatellatest(-).bilateraldorsalispedisarteriescanbepalpated.edemainthelowerextremities(+++).
Nervesystem:
Biceps,triceps,radioperiosteal,andabdominalwallreflexesnormal.kneejerkandAchillesjerkarealsonormal.babinski'
opspenheim'
s,chaddock'
s,gonredgoantiv'
e.sHoffmannsign(-).Necktetany(-)Kernigsign(-).Brudzinskisign(-).Nopatellarorankleclonus.
Laboratoryfindings:
HBsAg(+),HBsAb(+).HBsAb-IgG(+),PreS1(+).HBV-DNA5.410E+4copies/ml,AFP13.91mg/ml(2012.6.29,GH)
MRI:
hepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.
SummaryThepatientnamedDuDonghe,male,is53yearsold,admissionwiththechiefcomplaintofweaknessfor1year,moreseverewithedemainlowerlimbsforhalfayearinJuly16th2012.
1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Hewenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoreseverewithedemainlower
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