英文肝硬化完整大病历Word格式.docx

英文肝硬化完整大病历Word格式.docx

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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,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.

PhysicalExamination

Temperature:

37.1Cpulserate:

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.thethoracicrespirationpresent.R18/min,symmetryinbothsides.Symmetryandnoabnormalityofthe2breasts.

Lungs:

Inspections:

nobulgesorrecessionoftheintercostalsspacesduringrespiration.Respiratorymovementequalinbothsidesandregular.nodyspneaorthreeconcavesign.

Palpation:

symmetryrespiratorymovementinthetwosides,noincreaseordecreaseofvocalfremitus.Nopleuralfrictionfremitus.nosubcutaneouscrepitation.

Percussion:

resonanceinalloverthelungfields.5cminwidthofapexes,andthelowermarginoflungat6th,8th,10thonmidclavicular,midaxillary,midcapularlinerespectivelyinbothleftandrightside.Themovementsofthelowermarginofthelungsare6cminbothleftandrightside.

Auscultation:

roughofvesicularbreathingsoundsalloverthelungfields.fineralesareheardinbilateralsubpulmonicparts.norhonchis.normalofvocalresonance.Nopleuralfrictionsound.

Heart:

Inspection:

noprecordialbulging.Apicalimpulseinthe5thICS1cminsideofleftmidclavicularlinewithanareaof2cmindiameter.

apicalimpulseanditsareaasthatininspection.Regular,normalintensity.Nopericardialfrictionrubsorthrill.

relativecardiacdullnessshownasfollows:

Right（cm）

ICS

Left（cm）

2

Ⅱ

Ⅲ

4

3

Ⅳ

6

Ⅴ

7

Thedistancebetweentheleftmidclvicularlineandthemidsternallineis8cm.

HR101/minwithregularrhythm,heartsoundsclearandintensive.nomurmursatanyauscultationareaofthevalvula.Nopericardicalfrictionsound.

Radialarteries:

pulserate101/min,withregularrhythm,equalinbothsides,normalintensity.

Perivascularsigns:

nocapillarypulsation,waterhammerpulse,pistol-shotsoundsandDuroziez’smurmur.nopulsedeficit,andpulsealternant.

Abdomen:

symmetry.bulgeabdomen.normalabdominalrespiration.Novisiblegastrointestinalwaves.Novaricosity,scar,petechiaattheabdominalSkin.

tightenedabdominalwall,notendernessandreboundingtenderness.Nopalpablemass.

Liver:

notpalpable.

Gallbladder:

notpalpable.Negativeofmurphy’ssign.

Kidneys:

notpalpable.Notendernessintheanysiteofkidneysorureters.

Spleen:

Appendix:

notendernessattheMcburney’ssite.

tympanyinallovertheabdomen,shiftingdullness（+）.Nopercussivepainofliverandspleen.Theuppermarginofliveratthe5thICSintherightmidcalvicularline

normalborhorygmus,4/min,nomurmurofvessels.Nofrictionrubs.

Anusandrectum:

notexamined.

Spine:

nolordosis,kyphosis,orscoliosis.Notendernessandpunchingtenderness.NoLimitationofmovement.Nochangesinthelocalskin.

Extremities:

symmetry,nodeformity.freemotion.musclestrengthisnormal.nojointredness,swollen,tendernessorhotness.Noacropachy,koilonychia,floatingpatellatest（-）.bilateraldorsalispedisarteriescanbepalpated.edemainthelowerextremities（+++）.

Nervesystem:

Biceps,triceps,radioperiosteal,andabdominalwallreflexesnormal.kneejerkandAchillesjerkarealsonormal.babinski’s,oppenheim’s,chaddock’s,gordon’snegative.Hoffmannsign（-）.Necktetany（-）Kernigsign（-）.Brudzinskisign（-）.Nopatellarorankleclonus.

Laboratoryfindings:

HBsAg（+）,HBsAb（+）.HBsAb-IgG（+）,PreS1（+）.HBV-DNA5.410E+4copies/ml,AFP13.91mg/ml（2012.6.29,GH）

MRI:

hepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.

Summary

ThepatientnamedDuDonghe,male,is53yearsold,admissionwiththechiefcomplaintofweaknessfor1year,moreseverewithedemainlowerlimbsforhalfayearinJuly16th2012.

1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Hewenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment（thedetailofdrugsusedisunclear）.Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemo