英文肝硬化完整大病历.docx
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英文肝硬化完整大病历.docx
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英文肝硬化完整大病历
CompleteMedicalHistory
Generalinformation
Name:
DuDongheSex:
male
Profession:
retiredworkerAge:
53years
Nativeplace:
TianJinAddress:
shengheDepartmentpujijianRoadhebeidistricttianjin
Maritalstate:
marriedNationality:
Han
Dateofadmission:
July16th2012Dateofhistorytaking:
July16th2012
Narrator:
thepatient'sdaughterReliabilityofthehistory:
reliable
TheHistory
ChiefComplaint:
weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.
PresentIllness:
1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainordiarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoresevere,withedemainlowerlimbs,abdominaldistensionandheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA10E+4copies/ml,ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+),PreS1(+).HealsohadaMRscanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvanceddiagnosisandtreatment.Sincethedisease,nochangesinconsciousness
appetite,bodyweight.andnormalofstoolwhilelessofurine.
Pasthistory:
thepatientbecameblind50yearshehasahistoryofhepatitisBfor26years.Nohistoryofchronicdiseaseslikehypertension,CADandmellitusdiabetics.Notuberculosis.Nohistoryoftrauma,operationandbloodtransfusion.Hewasallergictopenicillinandsulfahistoryofvaccinationisunclear.
ReviewofSystems:
Respiratorysystem:
nohistoryofchroniccough,expectoration,hemoptysis,chestpain,orshortofbreath.
Circulationsystem:
halfayearagehehadtheedemaatthelowerhistoryofdyspnea,palpitationorchestpain.Nodizziness,historyofhypertension.
Digestivesystem:
halfayearagehebegantohavetheabdominaldistentionandhistoryofanorexia,,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.NohistoryofbleedingandrepeatedMRscanshowssplenomegaly.
.
MetabolicandEndocrinesystem:
noabnormalcoldorhotfeeling,hidrosis多汗,headache,impairedvision,polyphagia食欲过盛,polyuriadistributedchangeoftemperandintelligence.
Nervoussystem:
Noheadache,projectilevomiting.nosyncope,spasm,impairedvision,abnormalsensationormotion.Nochangeofpersonality.nomania躁狂,depressionorhallucination.
Motorsystem:
Nospasm,atrophyorpalalysis.Nojointredswollen,hot,painorlimitationofmotion.Notraumaorfracture.
Personalhistory:
borninhernativeplaceandlivinginTianjin.Nohistoryofexposuretoradioactivehabitsofdrinkingorsmoking.
MaritalHistory:
.Marriedat30yearsoldandhavingason.hissonandwifearebothhealthy.
Familyhistory:
hismotherhadthehepatitisotherfamilyhistoryofhereditydiseases,orMD,CAD,hypertensionect.
PhysicalExamination
Temperature:
pulserate:
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ormotionsoftheeyeballsinanydirection.Equalandroundpupilsatbothsideswithdiameter4mm,Nolightreflexes,noaccommodationandconvergencereflexes.Vision,visualfieldandeyegroudnotexamined.
Ears:
nodeformity.noabnormalsecretionfromexternalcanals.Nored,tenderness,swolleninthemastoid.Roughtestednormalhearing.
Nose:
nodeformity.Nodeviationofseptumnasi.Noalaflutter.Noedema,abnormalsecr
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