英文--肝硬化完整大病歷

1、Complete Medical HistoryGen eral in formati onName: Du Don gheSex: maleProfession : retired worker Age:53 yearsNative place: Tia n Jin Address:she nghe Departme nt pujijia n Road hebei district tianj inMarital state: marriedNati on ality: HanDate of admission: July 16h 2012 Date of history taking :J

2、uly 16th 2012Narrator: the patients daughter Reliability of the history: reliableThe HistoryChief 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 beganto feel weak ness No headache, dizzy, palp

3、itatio n, short ness, abdo minal 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 symp

4、tom became more severewith edema in lower limbs , abdo minal diste nsion and bulgeNo headache, dizzy, palpitation, shortness, tightness, abdominal pain or diarrhea . So the patientwent to the out-patie nt departme nt of our hospital to check the HBV-DNA 5.4 10E+4copies/ml,AFP13.91 mg/ml,HBsAg(+),HBs

5、Ab(+).HBsAb-lgG (+), PreS1(+). He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repass ing. So he was accepted in our secti on for adva need diag no sis and treatme nt. Si nee the disease, no cha nges in con scious ness

6、,appetite, body weight .and normal of stool while less of urine.Past history : the patient becameblind 50 years ago.And he has a history of hepatitis B for 26years. No history of chronic diseaseslike hypertension, CAD and mellitus diabetics. No tuberculosis .No history of trauma, operation and blood

7、 transfusion. He 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, n

8、o history of dysp nea,palpitatio n or chest pai n. No dizz in ess, headache.No history of hyperte nsion.Digestive system: half a year age he bega n to have the abdo minal diste ntion and bulge .no history of ano rexia, , regurgitatio n 反流.No n ausea and vomiting. No history of constipation , diarrhe

9、a ,melena .Urogenital system: no history of swollen eyelids or lumbago 腰疼.No freque nt micturitio n, urge ncy of micturitio nor urod ynia. Nodysuria ,hematuria or retention and incontinence of urine .no history of acute or chr onic n ephritis.Hemopoeltic system: 1 years ago the patient began to feel

10、 weakness and became more severe half a year ago. No pallid 蒼白 countenan c 面容,dizz in ess , daze 頭昏眼花,t inn itus 耳鳴.No history of bleed ing and repeated in fecti on s.The MR sea n shows sple no megaly.Metabolic and Endocrine system: no abnormal cold or hot feeling, hidrosis 多 汗,headache ,impaired vi

11、sion,polyphagia 食欲過(guò)盛,polyuria ect.normal distributed hair.no change of temper and intelligenee.Nervous system: No headache ,projectile vomiti ng . no syn cope ,spasm impaired visi on, abno rmal sen satio n or moti on. No cha nge of pers on ality .no ma nia 躁3王,depressi on or halluc in ati on.Motor s

12、ystem: No spasm, atrophy or palalysis. No joint red swollen, hot ,pai n or limitati on of moti on. No trauma or fracture.Personal history : born in her native place and living in Tianjin. No history of exposure to radioactive pois on .No habits of drinking or smok ing.Marital History Married at 30 y

13、ears old and having a son. his son and wife are both healthy.Family history : his mother had the hepatitis B.denying other family history of heredity diseases ,or MD, CAD, hyperte nsion ect.Physical Exam in ati onTemperature : 37.1C pulse rate: 101/min respiratory rate: 18/min blood pressure :130/80

14、mmHgGeneral appearanee : normal development and medium in nourished ,no abno rmal eon scious ness, good corporati on in exam in ati on. Free positi on.Ski n and mucous membra ne : No pallid , cyano sis, and jaun dice . no abno rmal pigme ntatio n and depigme ntati on . no erythma annu lare, petechia

15、 and spider an gioma. Normal elasticity of skig edema Superficial lymph no des : no enl argeme nt of the superficial lymph no des. Head and its orga ns:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shi ne.Eyes: no drop out of eyebrow and no madarosis ,no swoll

16、en or prolapse of eyelids. No pallor, granules follicles pectechiae of conjunctivae . tran spare nt of cor nea ,no n ebula ,keratoleukoma, malacia, ulcer or vascularization.No exophthalmos 眼球突出 or enophthalmosfree motions of the eye balls in any directi on . Equal and round pupils at both sides with

17、 diameter 4mm, No light reflexes, no accommodation and convergenee reflexes. Vision , visual field and eyegroud not exam ined.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 sep

18、tum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ven tilatio n. No tendern ess in any para nasal sinu ses.Buccal cavity : no pallid or cyano sis of lips ,also no dryn ess ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth,

19、 no caries. No bleeding or congestion Jead line in gums. Tongue was in midline ,with normal in motion. No redness and congestion in pharynx ,no deviati on of uvulae. No edema in ton sils.Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No

20、rigidity .no enlargement of thyroid gla nds ,and the trachea in the cen teral positi on. No murmur. Negative of 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 bot

21、h sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular. no dysp nea or three con cave sig n.Palpatio n : symmetry respiratory moveme nt in the two sides, no in

22、 crease or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitatio n.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th ,8th ,10thonmidclavicular ,midaxillary5midcapular line respectively in both left and rig

23、ht side. The moveme nts of the lower margin of the lungs are 6 cm in both left and right side.Auscultation : rough of vesicular breathing sounds all over the lung fields.fi ne rales are heard in bilateral subpul monic parts no rhon chis .no rmal of vocal resonan ce. No pleural fricti on sound.Heart:

24、In specti on : no precordial bulgi ng. Apical impulse in the 5th ICS 1cm in side of left midclavicular line with an area of 2 cm in diameter.Palpation : apical impulse and its area as that in inspection. Regular,normal intensity. No pericardial friction rubs or thrill.Percussion: relative cardiac du

25、llness shown as follows:Right (cm)ICSLeft (cm)2n22皿43IV6V7The distance between the left midclvicular line and the midsternal line is 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 soun

26、d.Radial arteries: pulse rate 101/min, with regular rhythm, equal in both sides, no rmal inten sity .Perivascular sig ns : no capillary pulsati on, water hammer pulse ,pistol-shot sounds and Duroziez ' s murmur. no pulse deficit, and pulse alternant.Abdome n:Inspection : symmetry, bulge abdomen.

27、normal abdominal respiration. No visible gastro in test inal waves. No varicosity , scar,petechia at the abdominal Skin.Palpation : tightened abdominal wall ,no tenderness and rebounding tendern ess . No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphy ' s sign.Kid

28、n eys: not palpable. No ten der ness in the any site of kid neys or ureters. Splee n: not palpable.Appendix: no tenderness at the Mcburney' s site.Percussion: tympany in all over the abdomen, shifting dullness(+). No percussive pain of liver and splee n. The upper margin of liver at the 5th ICS

29、in the right midcalvicular lineAuscultation : normal borhorygmus, 4/min, no murmur of vessels. No fricti on rubs .Anus and rectum : not exam in ed.Spine: no lordosis, kyphosis, or scoliosis. No tendern ess and pun chi ng tenderness . No Limitation of movement. No changes in the local skin. Extremiti

30、es : symmetry, no deformity . free motion .muscle strength is normal.no joint redness ,swollen tenderness or hotness. No acropachy,koilonychia5floating patella test(-).bilateral dorsalis pedis arteries can be palpated, edema in the lower extremities(+).Nerve system: Biceps,triceps ,radioperiosteal ,

31、 and abdo minal wall reflexesno rmal. knee jerk and Achilles jerk are also no rmal. bab in ski 1 ppe nheim 1 s,chaddock ' s,gcnregativ' SHoffma nn sig n (-). Neck tetany (-) Kernig sign (-).Brudzinski sign (-).No patellar or ankle clo nus.Laboratory fin di ngs : HBsAg(+),HBsAb(+).HBsAb-lgG (

32、+), PreS1 (+). HBV-DNA 5.4 10E+4copies/ml,AFP13.91 mg/ml(2012.6.29,GH)MRI :hepatic cirrhosis,sple no megaly,portal hyperte nti on, gastricvarix,umbilical vein repassing.SummaryThe patient named Du Donghe ,male ,is 53years old,admission with the chief complaint of weakness for 1 year, more severe wit

33、h edema in lower limbs for half a year in July 16th 2012 .1 years ago ,without significant causes,the patient began to feel weak ness.Hewe nt to the hospital in his tow n, and checked his live fun cti on, shown the live is damaged,given liver-protecting treatment(the detail of drugs used is un clear

34、). But the symptom is not obviously lighte ned. And half a year ago ,the symptom became more severewith edema in lower limbs , abdominal distension and bulgeSo the patient went to the out-patient departme nt of our hospital to check the HBV-DNA 5.4 10E+4copies/ml,AFP13.91 mg/ml,HBsAg(+),HBsAb(+).HBsAb-lgG(+)JPreS1(+). He also had a MR sean of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repass