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 2012 Narrator: 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,withedema 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..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 other family 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 of conjunctivae .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. Tongue 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, no abnormal 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 funnelchest. 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 the lung 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 insideof 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, equal in 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. Novisible 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 lineAuscultation: normal borhorygmus, 4/min, no murmur of vessels. 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 arteriescan 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-patientdepartment 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.the patient became blind 50 years ago.And he has a history 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:Jin Dan。
