病生病例讨论 英文版概要1.docVIP

CIRRHOSIS硬化，肝硬化 PATIENT CASE Patient’s Chief Complaints患者主诉 Provided by wife: “My husband’s very confused and he has been acting strangely. This morning, he couldn’t answer my questions and seemed not to recognize me. I think that his stomach has been swelling up 膨胀again, too. He stopped drinking four years ago, but his cirrhosis肝硬化 seems to be getting worse.” HPI (History of present illness) S.G. is a 46 yo white male with a history of chronic慢性的alcoholism 酗酒and alcoholic cirrhosis.酒精性肝硬变 He was admitted to the hospital from the outpatient门诊病人 clinic诊所 with abdominal 腹部的swelling 肿胀and confusion. He has unintentionally 无意间gained 15 lbs 磅during the past four weeks. According to his wife, the patient has not been sleeping well for several weeks, has been feeling very lethargic（昏睡） for the past three days, can’t seem to remember appointments 约会lately, and, uncharacteristically,不典型地 has lost his temper with her several times in the last month. S.G.’s boss at work had also telephoned her last week concerned about his “unusual and violent behavior on the job.” PMH (Past medical history) Pneumonia 肺炎9 years ago that resolved 解决with antimicrobial 抗菌的therapy 治疗 Cirrhosis 肝硬化secondary to继发 heavy alcohol use大量饮酒 diagnosed诊断4 years ago with ultrasound超声波 and liver biopsy 活组织检查( micronodular小结的cirrhosis) H/O uncontrolled ascites腹水 and peripheral外围的 edema浮肿，水肿 (H/O: history of) H/O two upper 上部的，较高的GI升糖指数 hemorrhages出血 上消化道出血？from esophageal食管的 varices 静脉曲张 H/O anemia贫血 H/O E. coli-induced大肠杆菌引起的 bacterial peritonitis 细菌性腹膜炎4 years ago H/O acute急性的 pancreatitis胰腺炎 secondary to alcohol abuse饮酒过度 No history to suggest cardiac心脏的 or gallbladder 胆囊disease 翻译：没有心脏或者胆囊的疾病史 No previous diagnosis诊断 of viral病毒的 or autoimmune 自身免疫的hepatitis肝炎 翻译：先前没有病毒性或者自身免疫性肝炎的诊断 SURG外科 S/P appendectomy阑尾切除术 requiring blood transfusions 输血30 years ago S/P open-reduction开放复位internal内部的 fixation定影 of right femur大腿骨 secondary to继发 MVA摩托车车祸 5 years ago (SP: status post病后状态; MVA: motor vehicle accident)