英文--肝硬化完整大病历

CompleteMedicalHistoryGeneralinformationName:DuDongheProfession:retiredworkerNativeplace:TianJinSex:maleAge:53yearsAddress:shengheDepartmentpujijianRoadhebeidistricttianjinMaritalstate:marriedDateofadmission:July16th201216th2012Narrator:thepatient'sdaughterNationality:HanDateofhistorytaking:JulyReliabilityofthehistory:reliableTheHistoryChiefComplaint:weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.PresentIllness:!yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainordiarrhea•Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago/thesymptombecamemoresevere,withedemainlowerlimbszabdominaldistensionandbulge.Noheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea•Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml/AFP13.91mg/ml/HBsAg(+)/HBsAb(+).HBsAb-IgG(+),PreSl(+)・HealsohadaMRscanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvaneeddiagnosisandtreatment.Sincethedisease,nochangesinconsciousness,appetite,bodyweight.andnormalofstoolwhilelessofurine.Pasthistory:thepatientbecameblind50yearsago.AndhehasahistoryofhepatitisBfor26years.Nohistoryofchronicdiseaseslikehypertension,CADandmellitusdiabetics.Notuberculosis.Nohistoryoftrauma,operationandbloodtransfusion.Hewasallergictopenicillinandsulfadrugs.Thehistoryofvaccinationisunclear.ReviewofSystems:Respiratorysystem:nohistoryofchroniccoughzexpectoration,hemoptysisfchestpain,orshortofbreath.Circulationsystem:halfayearagehehadtheedemaatthelowerlimbs.nohistoryofdyspnea,palpitationorchestpain.Nodizziness,headache.Nohistoryofhypertension.Digestivesystem:halfayearagehebegantohavetheabdominaldistentionandbulge.nohistoryofanorexia,rregurgitation反流.Nonauseaandvomiting.Nohistoryofconstipation,diarrhea,melena•Urogenitalsystem:nohistoryofswolleneyelidsorlumbago腰疼.Nofrequentmicturition,urgencyofmicturitionorurodynia.Nodysuria,hematuriaorretentionandincontinenceofurine.nohistoryofacuteorchronicnephritis.Hemopoelticsystem:1yearsagothepatientbegantofeelweaknessandbecamemoreseverehalfayearago.Nopallid苍白countenance面容rdizziness厂daze头昏眼花力nnitus耳Q鸟.Nohistoryofbleedingandrepeatedinfections.TheMRscanshowssplenomegaly.■MetabolicandEndocrinesystem:noabnormalcoldorhotfeelinghidrosis多汗‘headacheJmpairedvision,polyphagia食欲过盛,polyuriaect.normaldistributedhair.nochangeoftemperandintelligence.Nervoussystem:Noheadache,projectilevomiting•nosyncope，spasmjmpairedvision,abnormalsensationormotion.Nochangeofpersonality.nomania躁狂zdepressionorhallucination.Motorsystem:Nospasm,atrophyorpalalysis.Nojointredswollen,hot,painorlimitationofmotion.Notraumaorfracture.Personalhistory:borninhernativeplaceandlivinginTianjin.Nohistoryofexposuretoradioactivepoison.Nohabitsofdrinkingorsmoking.MaritalHistory:.Marriedat30yearsoldandhavingason.hissonandwifearebothhealthy.Familyhistory:hismotherhadthehepatitisB.denyingotherfamilyhistoryofhereditydiseases,orMDZCADZhypertensionect.PhysicalExaminationTemperature:37.1Cpulserate:101/minrespiratoryrate:18/minbloodpressure:130/80mmHgGeneralappearance:normaldevelopmentandmediuminnourished,noabnormalconsciousnessfgoodcorporationinexamination.Freeposition.Skinandmucousmembrane:Nopallidzcyanosis,andjaundice•noabnormalpigmentationanddepigmentation•noerythmaannulare,petechiaandspiderangioma.Normalelasticityofskin,noedema.Superficiallymphnodes:noenlargementofthesuperficiallymphnodes.Headanditsorgans:Skull:nodeformity,tendernessormass.Evenlydistributedhairwithblackcolorandshine.Eyes:nodropoutofeyebrowandnomadarosis,noswollenorprolapseofeyelids.Nopallor;granulesfolliclespectechiaeofconjunctivae.transparentofcornea小onebula^eratoleukoma,malacia,ulcerorvascularization.Noexophthalmos眼球突出orenophthalmos.freemotionsoftheeyeballsinanycfeewtieR.Equalandroundpupilsatbothsideswithdiameter4mm,Nolightreflexes,noaccommodationandconvergeneereflexes.Ears:nodeformity.noabnormalsecretionfromexternalcanals.Nored,tenderness,swolleninthemastoid.Roughtestednormalhearing.Nose:nodeformity.Nodeviationofseptumnasi.Noalaflutter.Noedemaabnormalsecretion,andcongestionofthemembrane•goodventilation.Notendernessinanyparanasalsinuses.Buccalcavity:nopallidorcyanosisoflips月Isonodryness,herpessimplex.Nocongestion,petechiaorulcerinthebuccalmembrane•32teeth,nocaries.Nobleedingorcongestion」eadlineingums.Tonguewasinmidline,withnormalinmotion.Norednessandcongestioninpharynx,nodeviationofuvulae.Noedemaintonsils.Neck:symmetry.noenlargementofexternaljugularvein,noabnormalpulsationofcarotidarteriesorveins.Norigidity.noenlargementofthyroidglands,andthetracheainthecenteralposition.Nomurmur.Negativeofhepatojugularreflux.Chest:symmetry.Nodeformity.Nobarrelchest,pigeonchestorfunnelchestNotendernessoverthechest.thethoracicrespirationpresent.R18/min,symmetryinbothsides.Symmetryandnoabnormalityofthe2breasts.Lungs:Inspections:nobulgesorrecessionoftheintercostalsspacesduringrespiration.Respiratorymovementequalinbothsidesandregular.nodyspneaorthreeconcavesign.Palpation:symmetryrespiratorymovementinthetwosides,noincreaseordecreaseofvocalfremitus.Nopleuralfrictionfremitus•nosubcutaneouscrepitation.Percussion:resonaneeinalloverthelungfields.5cminwidthofapexes,andthelowermarginoflungat6th,8th,10thonmidclavicular/midaxillary,midcapularlinerespectivelyinbothleftandrightside.Themovementsofthelowermarginofthelungsare6cminbothleftandrightside.Auscultation:roughofvesicularbreathingsoundsalloverthelungfields.fineralesareheardinbilateralsubpulmonicparts.norhonchis・normalofvocalresonance.Nopleuralfrictionsound.Heart:Inspection:noprecordialbulging.Apicalimpulseinthe5thICSlcminsideofleftmidclavicularlinewithanareaof2cmindiameter.Palpation:apicalimpulseanditsareaasthatininspection.Regular,normalintensity.Nopericardialfrictionrubsorthrill.Percussion:relativecardiacdullnessshownasfollows:Right(cm)ICSLeft(cm)2n22m43IV6V7Thedistancebetweentheleftmidclvicularlineandthemidsternallineis8cm.Auscultation: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.Palpation:tightenedabdominalwall，notendernessandreboundingtenderness•Nopalpablemass.Liver:notpalpable.Gallbladder:notpalpable.Negativeofmurphy1ssign.Kidneys:notpalpable.Notendernessintheanysiteofkidneysorureters.Spleen:notpalpable.Appendix:notendernessattheMcburney'ssite.Percussion:tympanyinallovertheabdomen,shiftingdullness(+).Nopercussivepainofliverandspleen.Theuppermarginofliveratthe5thICSintherightmidcalvicularlineAuscultation:normalborhorygmus,4/min,nomurmurofvessels.Nofrictionrubs.Anusandrectum:notexamined.Spine:nolordosis,kyphosis,orscoliosis.Notendernessandpunchingtenderness•NoLimitationofmovement.Nochangesinthelocalskin.Extremities:symmetry,nodeformity•freemotion.musclestrengthisnormal.nojointredness,swollenRendernessorhotness.Noacropachy.koilonychiajloatingpatellatest(-).bilateraldorsalispedisarteriescanbepalpated,edemainthelowerextremities®++)•Nervesystem:Biceps,triceps/adioperiostealzandabdominalwallreflexesnormal,kneejerkandAchillesjerkarealsonormal.babinski's.oppenheim's,chaddock"s,gordon"snegative.Hoffmannsign(-).Necktetany(-)Kernigsign(-).Brudzinskisign(-).Nopatellarorankleclonus.Laboratoryfindings:HBsAg(+),HBsAb(+).HBsAb-IgG(+)/PreSl(+)・HBV・DNA5.410E+4copies/ml/AFP13.91mg/ml(2012.6.29/GH)MRI:hepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.SummaryThepatientnamedDuDonghe,male,is53yearsoldzadmissionwiththechiefcomplaintofweaknessfor1year;moreseverewithedemainlowerlimbsforhalfayearinJuly16th2012.1yearsago.withoutsignificantcauses’thepatientbegantofeelweakness.Hewenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver・protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoresevere.withedemainlowerlimbs,abdominaldistensionandbulge.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml/AFP13.91mg/mlzHBsAg(+)/HBsAb(+).HBsAb-IgG(+),PreSl(+).HealsohadaMRseanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvanceddiagnosisandtreatment.thepatientbecameblind50yearsago.AndhehasahistoryofhepatitisBfor逻years.Hewasallergictopenicillinandsulfadrugs.Hehasnohistoryofexposuretoradioactivepoison.andhismotherhadthehepatitisB.PE:T:37.1C,P:101/minR:18/minBp130/80mmHg,normaldevelopment,moderatelynourished,clearcounsciousness.Goodcorporationinphysicalexamination,roughofvesicularbreathingsoundsalloverthelungfields.fineralesareheardinbilateralsubpulmonicparts.HRlOlbpm’withregularrhythm,nomurmursatanyauscultationareaofthevalvula,bulgeabdomeretightenedabdominalwall，notendernessandreboundingtenderness.LiverandSpleenarenotpalpable.shiftingdullness(+),edemaintheIowerextremities(+++)Laboratoryfindings:HBsAg(+),HBsAb(+).HBsAb-IgG(+)/PreSl(+)・HBV・DNA5.410E+4copies/ml/AFP13.91mg/ml(2012.6.29/GH)MRI:hepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Impression:l.HBVcirrhosisPortalhypertensiongastricvarix2.HypersplenismSignature:JinDa