英文--肝硬化完整大病历.doc

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 patients 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 Syste