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

Date of admission: July 16th 2012 Date of history taking :July 16th 2012 Narrator: 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 lightened. And half a year ago ,the symptom became more severe,with 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 more severe half a year ago. No pallid 苍白countenance面容,dizziness ,daze头昏眼花,tinnitus耳鸣. No history of bleeding and repeated infections.The MR scan shows splenomegaly.

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Metabolic and Endocrine system:no abnormal cold or hot feeling, hidrosis多汗,headache ,impaired vision,polyphagia 食欲过盛,polyuria ect.normal distributed hair.no change of temper and intelligence.

Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania躁狂 ,depression or hallucination.

Motor system: No spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture.

Personal history : born in her native place and living in Tianjin. No history of exposure to radioactive poison.No habits of drinking or smoking.