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:
shengheDepartmentpujijianRoad
hebeidistricttianjin
Maritalstate:
marriedNationality:
Han
thth2012Dateofhistorytaking:
July162012Dateofadmission:
July16Narrator:
thepatient'sdaughterReliabilityofthehistory:
reliable
TheHistory
ChiefComplaint:
weaknessfor1year,moreseverewithedemainlower
limbsforhalfayear.
PresentIllness:
1yearsago,withoutsignificantcauses,thepatientbeganto
feelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainor
diarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislive
function,showntheliveisdamaged,givenliver-protectingtreatment(the
detailofdrugsusedisunclear).Butthesymptomisnotobviously
with
severemorebecamesymptom,theagoyearahalfAndlightened.
edemainlowerlimbs,abdominaldistensionandbulge.Noheadache,dizzy,
palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatient
wenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA
5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+),
PreS1(+).HealsohadaMRscanoftheupperabdomen,shownhepatic
cirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalvein
repassing.Sohewasacceptedinoursectionforadvanceddiagnosisand
treatment.Sincethedisease,nochangesinconsciousness
appetite,bodyweight.andnormalofstoolwhilelessofurine.
Pasthistory:
thepatientbecameblind50yearsago.Andhehasahistoryof
hepatitisBfor26years.Nohistoryofchronicdiseaseslikehypertension,
CADandmellitusdiabetics.Notuberculosis.Nohistoryoftrauma,
operationandbloodtransfusion.Hewasallergictopenicillinandsulfa
drugs.Thehistoryofvaccinationisunclear.
ReviewofSystems:
Respiratorysystem:
nohistoryofchroniccough,expectoration,
hemoptysis,chestpain,orshortofbreath.
Circulationsystem:
halfayearagehehadtheedemaatthelower
limbs.nohistoryofdyspnea,palpitationorchestpain.Nodizziness,
headache.Nohistoryofhypertension.
Digestivesystem:
halfayearagehebegantohavetheabdominaldistention
andbulge.nohistoryofanorexia,,regurgitation反流.Nonauseaand
vomiting.Nohistoryofconstipation,diarrhea,melena.
Urogenitalsystem:
nohistoryofswolleneyelidsorlumbago腰疼.No
frequentmicturition,urgencyofmicturitionorurodynia.No
dysuria,hematuriaorretentionandincontinenceofurine.nohistoryofacute
orchronicnephritis.
Hemopoelticsystem:
1yearsagothepatientbegantofeelweaknessand
became
more
severe
half
a
year
ago.
No
pallid
苍白countenance面容,dizziness,daze头昏眼花,tinnitus耳鸣.Nohistory
ofbleedingandrepeatedinfections.TheMRscanshowssplenomegaly.
.
MetabolicandEndocrinesystem:
noabnormalcoldorhotfeeling,
hidrosis多汗,headache,impairedvision,polyphagia食欲过盛,polyuria
ect.normaldistributedhair.nochangeoftemperandintelligence.
Nervous
system:
No
headache
projectile
vomiting
.
no
syncope,spasm,impairedvision,abnormalsensationormotion.Nochange
ofpersonality.nomania躁狂,depressionorhallucination.
Motorsystem:
Nospasm,atrophyorpalalysis.Nojointredswollen,
hot,painorlimitationofmotion.Notraumaorfracture.
Personalhistory:
borninhernativeplaceandlivinginTianjin.Nohistory
ofexposuretoradioactivepoison.Nohabitsofdrinkingorsmoking.
MaritalHistory:
.Marriedat30yearsoldandhavingason.hissonand
wifearebothhealthy.
Familyhistory:
hismotherhadthehepatitisB.denyingotherfamily
historyofhereditydiseases,orMD,CAD,hypertensionect.
PhysicalExamination
Temperature:
37.1Cpulserate:
101/minrespiratoryrate:
18/min
bloodpressure:
130/80mmHg
Generalappearance:
normaldevelopmentandmediuminnourished,no
abnormalconsciousness,goodcorporationinexamination.Freeposition.
Skinandmucousmembrane:
Nopallid,cyanosis,andjaundice.no
abnormalpigmentationanddepigmentation.noerythmaannulare,petechia
andspiderangioma.Normalelasticityofskin,noedema.
Superficiallymphnodes:
noenlargementofthesuperficiallymphnodes.
Headanditsorgans:
Skull:
nodeformity,tendernessormass.Evenlydistributedhairwithblack
colorandshine.
Eyes:
nodropoutofeyebrowandnomadarosis,noswollenorprolapseof
.
conjunctivaeofpectechiae,folliclesgranulespallor,Noeyelids.
transparentofcornea,nonebula,keratoleukoma,malacia,ulceror
vascularization.Noexophthalmos眼球突出orenophthalmos.freemotions
oftheeyeballsinanydirection.Equalandroundpupilsatbothsideswith
diameter4mm,Nolightreflexes,noaccommodationandconvergence
reflexes.Vision,visualfieldandeyegroudnotexamined.
Ears:
nodeformity.noabnormalsecretionfromexternalcanals.Nored,
tenderness,swolleninthemastoid.Roughtestednormalhearing.
Nose:
nodeformity.Nodeviationofseptumnasi.Noalaflutter.No
edema,abnormalsecretion,andcongestionofthemembrane.good
ventilation.Notendernessinanyparanasalsinuses.
Buccalcavity:
nopallidorcyanosisoflips,alsonodryness,herpessimplex.
Nocongestion,petechiaorulcerinthebuccalmembrane.32teeth,no
caries.Nobleedingorcongestion,leadlineingums.Tonguewasin
midline,withnormalinmotion.Norednessandcongestioninpharynx,no
deviationofuvulae.Noedemaintonsils.
Neck:
symmetry.noenlargementofexternaljugularvein,noabnormal
pulsationofcarotidarteriesorveins.Norigidity.noenlargementofthyroid
glands,andthetracheainthecenteralposition.Nomurmur.Negativeof
hepatojugularreflux.
funnel
orchest,pigeonchestbarrelNodeformity.Nosymmetry.:
Chest
chest.Notendernessoverthechest.thethoracicrespirationpresent.R
18/min,symmetryinbothsides.Symmetryandnoabnormalityofthe2
breasts.
Lungs:
Inspections:
nobulgesorrecessionoftheintercostalsspacesduring
respiration.Respiratorymovementequalinbothsidesandregular.no
dyspneaorthreeconcavesign.
Palpation:
symmetryrespiratorymovementinthetwosides,noincrease
ordecreaseofvocalfremitus.Nopleuralfrictionfremitus.nosubcutaneous
crepitation.
Percussion:
resonanceinalloverthelungfields.5cminwidthof
ththth
on
8,10lowerapexes,andthemarginoflungat6midclavicular,midaxillary,midcapularlinerespectivelyinbothleftandright
side.Themovementsofthelowermarginofthelungsare6cminbothleft
andrightside.
Auscultation:
roughofvesicularbreathingsoundsalloverthelung
fields.fineralesareheardinbilateralsubpulmonicparts.norhonchis.normal
ofvocalresonance.Nopleuralfrictionsound.
Heart:
thICS1cminside
:
noprecordialbulging.Apicalimpulseinthe5Inspection
ofleftmidclavicularlinewithanareaof2cmindiameter.
Palpation:
apicalimpulseanditsareaasthatininspection.Regular,normal
intensity.Nopericardialfrictionrubsorthrill.
Percussion:
relativecardiacdullnessshownasfollows:
Right(cm)ICSLeft(cm)
22Ⅱ4Ⅲ2
6Ⅳ3
7
ⅤThedistancebetweentheleftmidclvicularlineandthemidsternallineis
8cm.
Auscultation:
HR101/minwithregularrhythm,heartsoundsclearand
intensive.nomurmursatanyauscultationareaofthevalvula.No
pericardicalfrictionsound.
Radialarteries:
pulserate101/min,withregularrhythm,equalinboth
sides,normalintensity.
Perivascularsigns:
nocapillarypulsation,waterhammerpulse,pistol-shot
soundsandDuroziez'smurmur.nopulsedeficit,andpulsealternant.
Abdomen:
No
respiration.abdominal.normalabdomenbulgesymmetry.:
Inspection
visiblegastrointestinalwaves.Novaricosity,scar,petechiaatthe
abdominalSkin.
Palpation:
tightenedabdominalwall,notendernessandrebounding
tenderness.Nopalpablemass.
Liver:
notpalpable.
Gallbladder:
notpalpable.Negativeofmurphy'ssign.
Kidneys:
notpalpable.Notendernessintheanysiteofkidneysorureters.
Spleen:
notpalpable.
Appendix:
notendernessattheMcburney'ssite.
Percussion:
tympanyinallovertheabdomen,shiftingdullness(+).No
thICSpercussivepainofliverandspleen.Theuppermarginofliveratthe5intherightmidcalvicularline
Auscultation:
normalborhorygmus,4/min,nomurmurofvessels.No
frictionrubs.
Anusandrectum:
notexamined.
Spine:
nolordosis,kyphosis,orscoliosis.Notendernessandpunching
tenderness.NoLimitationofmovement.Nochangesinthelocalskin.
Extremities:
symmetry,nodeformity.freemotion.musclestrengthis
normal.nojointredness,swollen,tendernessorhotness.No
acropachy,koilonychia,floatingpatellatest(-).bilateraldorsalispedisarteries
canbepalpated.edemainthelowerextremities(+++).
Nervesystem:
Biceps,triceps,radioperiosteal,andabdominalwallreflexes
normal.
knee
jerk
and
Achilles
jerk
are
also
normal.
babinski's,oppenheim's,chaddock's,gordon'snegative.Hoffmannsign(-).
Necktetany(-)Kernigsign(-).Brudzinskisign(-).Nopatellarorankle
clonus.
Laboratoryfindings:
HBsAg(+),HBsAb(+).HBsAb-IgG(+),PreS1(+).
HBV-DNA5.410E+4copies/ml,AFP13.91mg/ml(2012.6.29,GH)
MRI:
hepatic
cirrhosis,splenomegaly,portal
hypertention,gastric
varix,umbilicalveinrepassing.
Summary
ThepatientnamedDuDonghe,male,is53yearsold,admissionwiththe
chiefcomplaintofweaknessfor1year,moreseverewithedemainlower
th2012.
16limbsforhalfayearinJuly
1year
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