英文--肝硬化完整大病历.pdfVIP

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