英文--肝硬化完整大病历

Complete Medical History General informationName: Du Donghe Sex: maleProfession : retired worker Age:53 yearsNative place: Tian Jin Address:shenghe Department pujijian Road hebei district tianjinMarital state: married Nationality: HanDate of admission: July 16th 2012 Date of history taking :July 16th 2012Narrator: the patient's daughter Reliability of the history: reliableThe HistoryChief 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 5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-Ig G(+), 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. Notuberculosis .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. Nohistory of bleeding and repeated infections.The MR scan shows splenomegaly..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.Marital History:. Married at 30 years old and having a son. his son and wife are both healthy.Family history: his mother had the hepatitis B.denying otherfamily history of heredity diseases ,or MD, CAD, hypertension ect.Physical Examination Temperature: 37.1C pulse rate: 101/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination. Free position.Skin and mucous membrane: No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spider angioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enlargement of the superficial lymph nodes.Head and its organs:Skull: no deformity, tenderness or mass. Evenly distributed hair with black color and shine.Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae ofconjunctivae . transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos 眼球突出or enophthalmos.free motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, No light reflexes, no accommodation and convergence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. T ongue was in midline ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils.Neck: symmetry . no enlargement of external jugular vein, noabnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux. Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th,8th,10th on midclavicular ,midaxillary,midcapular line respectively in both left and right side. The movements of the lower margin of the lungs are 6 cm in both left and right side. Auscultation: rough of vesicular breathing sounds all over thelung fields.fine rales are heard in bilateral subpulmonic parts.no rhonchis .normal of vocal resonance. No pleural friction sound. Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill. Percussion: relative cardiac dullness shown as follows:The distance between the left midclvicular line and the midsternal line is 8cm.Auscultation: HR 101/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound.Radial arteries: pulse rate 101/min, with regular rhythm, equalin both sides, normal intensity .Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziez’s murmur . no pulse deficit, and pulse alternant.Abdomen:Inspection: symmetry. bulge abdomen.normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominal Skin.Palpation: tightened abdominal wall ,no tenderness and rebounding tenderness . No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphy’s sign. Kidneys: not palpable. No tenderness in the any site of kidneys or ureters.Spleen: not palpable.Appendix: no tenderness at the Mcburney’s site. Percussion: tympany in all over the abdomen, shifting dullness(+). No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular line Auscultation: normal borhorygmus, 4/min, no murmur ofvessels. No friction rubs .Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. No tenderness and punching tenderness . No Limitation of movement. No changes in the local skin.Extremities: symmetry, no deformity . free motion .muscle strength is normal.no joint redness ,swollen ,tenderness or hotness. No acropachy,koilonychia,floating patella test(-).bilateral dorsalis pedis arteries can be palpated. edema in the lower extremities(+++).Nerve system: Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal. knee jerk and Achilles jerk are also normal. babinski’s ,oppenheim’s,chaddock’s,gordon’s negative. Hoffmann sign (-). Neck tetany (-) Kernig sign (-).Brudzinski sign (-).No patellar or ankle clonus.Laboratory findings: HBsAg(+),HBsAb(+).HBsAb-IgG(+), PreS1(+). HBV-DNA 5.4 10E+4copies/ml,AFP13.91mg/ml(2012.6.29,GH)MRI : hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing.SummaryThe patient named Du Donghe ,male ,is 53years old,admission with the chief complaint of weakness for 1 year, more severe with edema in lower limbs for half a year in July 16th 2012 .1 years ago ,without significant causes,the patient began to feel weakness.He 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.So the patient went to the out-patient department of our hospital to check the HBV-DNA 5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-Ig G(+), 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.the patient became blind 50 years ago.And he has ahistory of hepatitis B for 26years. He was allergic to penicillin and sulfa drugs.He has no history of exposure to radioactive poison.and his mother had the hepatitis B.PE: T:37.1C ,P: 101/min R: 18/min Bp 130/80mmHg,normal development, moderately nourished, clear counsciousness. Good corporation in physical examination. rough of vesicular breathing sounds all over the lung fields.fine rales are heard in bilateral subpulmonic parts.HR101bpm,with regular rhythm. no murmurs at any auscultation area of the valvula. bulge abdomen,tightened abdominal wall ,no tenderness and rebounding tenderness. Liver and Spleen are not palpable.shifting dullness(+),edema in the lower extremities(+++)Laboratory findings: HBsAg(+),HBsAb(+).HBsAb-IgG(+), PreS1(+). HBV-DNA 5.4 10E+4copies/ml,AFP13.91mg/ml(2012.6.29,GH)MRI : hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing.Impression: 1.HBV cirrhosisPortal hypertensiongastric varix2.HypersplenismSignature:JinDan。

肝硬化大病历
肝硬化是一种常见的肝脏疾病，其主要特点是肝脏组织发生不可逆性的纤维化和结缔组织增生，导致肝功能逐渐恶化，最终发展为肝功能衰竭。

下面是一位患有肝硬化的患者的病历。

患者姓名：王先生
性别：男
年龄：56岁
职业：退休工人
初诊日期：2020年7月1日
患者主诉：肝区酸痛、腹胀、乏力、食欲减退、黄疸等症状已有一年，加重一周。

既往病史：患者有高血压、糖尿病等慢性病史，多年饮酒史。

体格检查：肝区有压痛、肝大明显，腹水征阳性。

实验室检查：ALT 68 U/L（正常值<40 U/L）、AST 78 U/L（正常值<40 U/L）、总胆红素 72 μmol/L（正常值<20 μmol/L）、白蛋白 30 g/L（正常值35-55 g/L）、凝血酶原时间延长（14秒）。

影像学检查：腹部超声检查显示肝脏弥漫性回声增高，门静脉高压，脾脏肿大，胆囊壁增厚，腹水征象明显。

诊断：肝硬化，门脉高压综合征。

治疗方案：给予维持治疗，包括禁酒、低蛋白饮食、支持疗法等，同时进行症状缓解治疗，如利尿剂、肝素钠、抗感染等。

定期进行肝功能检查，观察病情变化，及时调整治疗方案。

预后：肝硬化是一种不可逆性疾病，预后与病情的严重程度和治疗的及时性有关。

患者需积极治疗，遵守医嘱，控制饮食和生活方式，早期发现和处理并发症，以延缓疾病的进展，提高生活质量。

总结：肝硬化是一种常见的肝脏疾病，患者需要积极治疗，控制病情，提高生活质量。

预防肝硬化的最好方法是戒酒，保持健康的生活方式。

及早治疗肝硬化并发症，保持规律的检查，是控制肝硬化病情的关键。

肝硬化病历模板基本信息姓名•姓名：XXX•性别：男/女•年龄：X岁•联系电话：XXXXXXXXXXX诊断日期•初次诊断时间：XXXX年X月X日•最近一次就诊时间：XXXX年X月X日主要症状•腹胀胀痛，XXX部位，X月前开始，X级别（1-10），以往有无类似症状？•厌食、腹泻、便秘、黄疸等，其他症状？就诊经过就诊医院/科室•就诊医院：XXXX医院•就诊科室：XXX科室检查结果•血常规：WBC：X，Hb：X，PLT：X•肝功能：–ALT：X，AST：X，TBil：X，DBil：X，ALP：X–凝血功能：PT：X，INR：X•影像学检查：B超、CT/MRI等（如有）–肝脏大小、形态、回声情况–肝内血流情况、门脉高压–肝硬化分级情况治疗方案•药物治疗：X药物，用药时间、剂量、疗程等•介入治疗：TIPS、肝动脉栓塞等（如有）•营养支持：口服/静脉注射营养液、饮食要求等•其他治疗方案随访记录随访时间•随访时间：XXXX年X月X日•下一次随访时间：XXXX年X月X日过去治疗效果•当前主要症状是否缓解？疼痛程度、频率、持续时间等•肝功能、凝血功能等检查结果是否有变化？•是否出现并发症、恶化情况？随访方案•继续原有治疗方案•加减药物/调整剂量/更换药物等，具体计划•补充营养、加强锻炼等建议•下一次随访时间及注意事项注意事项•饮食：低盐、低脂、易消化等•生活：避免饮酒、勿用毒品、保证充足睡眠等•孕产妇：应告知主治医生，避免用药过度造成不良影响。