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 patient's daughter Reliability of the history: reliable
The History
Chief Complaint: weakness for 1 year, more vereskype是什么 with edema in lower limbs for half a year.
Prent Illness:1 years ago ,without significant caus,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 责任意识the live is damaged, given liver-protecting treatment(the detail of drugs ud is unclear). But the symptom is not obviously lightened. when i was your man歌词And half a year ago ,the symptom became more vere,with edema in lower limbs , abdominal distension and bulge.柯卡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 ction refu的用法for advanced diagnosis and treatment. Since the dia, no changes in consciousness
, appetite, body weight .and normal of stool while less of urine.
Past history: the patient became blind 50test什么意思 years ago.And he has a history of hepatitis B f
or 26公式years. No history of chronic dias like hypertension, CAD and mellitus diabetics. No tuberculosis .No history of trauma, operation公费研究生 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 naua 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 inc
ontinence of urine .no history of acute or chronic nephritis.
Hemopoeltic system: 1 years ago the patient began to feel weakness and became more vere 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,al change of temper and intelligence.
Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal nsation 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 limitatio
n 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 dias ,or MD, CAD, hypertension ect.
Physical Examination
Temperature: 37.1julie and juliaC pul rate: 101/min respiratory rate: 18/min blood pressure:130/80mmHg
General 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.negroes
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 prolap 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 cretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.
No: no deformity. No deviation of ptum nasi. No ala flutter. No edema ,abnormal cretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinus.
