英文--肝硬化完整大病历

CompleteMedicalHistoryGeneralinformationName:DuDongheSex:maleProfession:retiredworkerAge:53yearsNativeplace:TianJinAddress:shengheDepartmentpujijianRoadhebeidistricttianjinMaritalstate:marriedNationality:HanDateofadmission:July16th2012Dateofhistorytaking:July16th2012Narrator:thepatient'sdaughterReliabilityofthehistory:reliableTheHistoryChiefComplaint:weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.PresentIllness:1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominalpainordiarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoresevere,withedemainlowerlimbs,abdominaldistensionandbulge.Noheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+),PreS1(+).HealsohadaMRscanoftheupperabdomen,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvanceddiagnosisandtreatment.Sincethedisease,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countenance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.nochangeoftemperandintelligence.Nervoussystem:Noheadache,projectilevomiting.nosyncope,spasm,impairedvision,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.PhysicalExaminationTemperature:37.1Cpulserate:101/minrespiratoryrate:18/minbloodpressure:130/80mmHgGeneralappearance: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orenophthalmos.freemotionsoftheeyeballsinanydirection.Equalandroundpupilsatbothsideswithdiameter4mm,Nolightreflexes,noaccommodationandconvergencereflexes.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.thethoracicresp