英文--肝硬化完整大病历

Complete Medical History General information

Name: Du Donghe Sex: male

Profession : retired worker Age:53 years

Native place: Tian Jin Address:shenghe Department pujijian Road

hebei district tianjin

Marital state: married Nationality: Han

th th 2012 Date of history taking :July 162012 Date of admission: July 16Narrator: the patient's daughter Reliability of the history: reliable The History

Chief 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 began to

feel weakness. No headache, dizzy, palpitation, shortness, abdominal 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

,with

severemore became symptom ,the ago year a half And lightened. edema in lower limbs , abdominal distension and bulge.No headache, dizzy,

palpitation, shortness, tightness, abdominal pain or diarrhea . So the patient

went to the out-patient department of our hospital to check the

HBV-DNA

5.4

10E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+), PreS1(+). He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing. So he was accepted in our section for advanced diagnosis and treatment. Since the disease, no changes in consciousness

, appetite, body weight .and normal of stool while less of urine.

Past history: the patient became blind 50 years ago.And he has a history of

hepatitis B for 26years. No history of chronic diseases like hypertension, CAD and mellitus diabetics. No tuberculosis .No history of trauma,

operation and blood 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.no history of dyspnea,palpitation or chest pain. No dizziness, headache.No history of hypertension.

Digestive system: half a year age he began to have the abdominal distention

and bulge.no history of anorexia, , regurgitation反流. No nausea and vomiting. No history of constipation , diarrhea ,melena .

Urogenital system: no history of swollen eyelids or lumbago腰疼. No

frequent micturition, urgency of micturition or urodynia. No

dysuria ,hematuria or retention and incontinence of urine .no history of acute

or chronic nephritis.

Hemopoeltic system: 1 years ago the patient began to feel weakness and

became