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1、CompleteMedicalHistoryGeneralinformationName:DuDongheSex:maleProfession:retiredworkerAge:53yearsNativeplace:TianJinAddress:shengheDepartmentpujijianRoadhebeidistricttianjinMaritalstate:marriedNationality:HanDateofadmission:July16th2012Dateofhistorytaking:July16th2012Narr
2、ator:thepatient'sdaughterReliabilityofthehistory:reliableTheHistoryChiefComplaint:weaknessfor1year,moreseverewithedemainlowerlimbsforhalfayear.PresentIllness:1yearsago,withoutsignificantcauses,thepatientbegantofeelweakness.Noheadache,dizzy,palpitation,shortness,abdominal
3、painordiarrhea.Thepatientwenttothehospitalinhistown,andcheckedhislivefunction,showntheliveisdamaged,givenliver-protectingtreatment(thedetailofdrugsusedisunclear).Butthesymptomisnotobviouslylightened.Andhalfayearago,thesymptombecamemoresevere,withedemainlowerlimbs,abdomin
4、aldistensionandbulge.Noheadache,dizzy,palpitation,shortness,tightness,abdominalpainordiarrhea.Sothepatientwenttotheout-patientdepartmentofourhospitaltochecktheHBV-DNA5.410E+4copies/ml,AFP13.91mg/ml,HBsAg(+),HBsAb(+).HBsAb-IgG(+),PreS1(+).HealsohadaMRscanoftheupperabdomen
5、,shownhepaticcirrhosis,splenomegaly,portalhypertention,gastricvarix,umbilicalveinrepassing.Sohewasacceptedinoursectionforadvanceddiagnosisandtreatment.Sincethedisease,nochangesinconsciousness,appetite,bodyweight.andnormalofstoolwhilelessofurine.Pasthistory:thepatientbeca
6、meblind50yearsago.AndhehasahistoryofhepatitisBfor26years.Nohistoryofchronicdiseaseslikehypertension,CADandmellitusdiabetics.Notuberculosis.Nohistoryoftrauma,operationandbloodtransfusion.Hewasallergictopenicillinandsulfadrugs.Thehistoryofvaccinationisunclear.ReviewofSyste
7、ms:Respiratorysystem:nohistoryofchroniccough,expectoration,hemoptysis,chestpain,orshortofbreath.Circulationsystem:halfayearagehehadtheedemaatthelowerlimbs.nohistoryofdyspnea,palpitationorchestpain.Nodizziness,headache.Nohistoryofhypertension.Digestivesystem:halfayearageh
8、ebegantohavetheabdominaldistentionandbulge.nohistoryofanorexia,,regurgitation反流.Nonauseaandvomiting.Noh
