消化英文交班yao mingshan

1、Yao Mingshan，a 63 years old male，was admitted due to“recurrent abdominal distenfor 4 years，aggravated with fever for 5days”4 years ago, the patiend abdominal distenwithout an obviouscause. He had fatigue and inappetence ,skin and sclera icterus , colorchang in urine and stool , bilateral lower limb

2、edema.He had no fever andchills , no hematemesis or hematochezia , no dizziness or syncope . Thepatient went to theTongDe hospital who was diagnosed of“hepatocirrhosis” andthen treated by diuretic and protein . Then theabdominaldistenwasreved.4 年来， Thepatientappearedabdominal distentime and time，was

3、 hospitalizedoTongDe hospital。Here he was given diuretic and protein，protected liverdrugs。Five days ago，the symptom of abdominal distenturnedmore grievous，腹围进行性增大，自己口服利尿药后，仍感腹胀不适，自诉发热，体温未测，伴随症状性质同前。Now for further diagnosis andtreatment, the patient was admittedo our hospital，was hospitalized anddia

4、gnosed with hepatitis hepatocirrhosis。Past history:The patiendnectomy because of “portal hyperten” 16 yearsago. He had no hyperten. No diabetes. No heart disease. No drug orfood allergic history. And her family history has no significant findings.Physical examination:Vital signs: Temperature was 38.

5、8 degree centigrade, Pulse was 100 beatsper minute, Respiratory Rate was 20 breath per minute, Blood Prerewas 135/69 millimeter mercury.General:Alert,nocyanosis,skinorscleraicterus,nocervicallymphadenopathy, no jugular venous disten, no palpable superfillymphadenopathy.Chest: regular heart rhythm, n

6、o murmurs,gs are clear, no rales.Abdomen:Wholeabdomenwasinflated.Nosplenomegalyorhepatomegaly, no shifting dullness. 移动性浊音阳性。Bowel soundsnormal, of 5 times per minute. Bilateral lower limb edema. The rectalexamination was negative.Laboratory test:(2009.9.8ourhospiyal)CBC:WBC:24500*106/ul,PT:20.2S,hs

7、CRP:26.7mg/dl,K+:2.97mol/dl,AST:57IU/L,ALP:160.6/IU/L,albumin:23mg/dl.Initial Impres:Hepatitis hepatocirrhosis 失代偿期 Child-Pugh C grade.Spontaneous bacterial peritonitisnectomy laterTreatment plan:1. Further examination: ECG, chest X-ray , the tumor markers ，abdominal ultrasound.2. drop temperature，f

8、illkalium， anti-infection。3.pump ascites in future。山，男，63 岁，因“反复腹胀 4 年，伴发热 5 天”入院。4 年前，患者无明显诱因下出现腹胀，伴乏力，皮肤眼白发黄，大小便颜色加深，双下肢浮肿，指按可凹。无发热，无呕血，无黑便，无清晨眼脸水肿，无腹痛，无胸闷气急，无神志不清。患者就诊于省立同德医院，拟“肝硬化”，给予利尿药，白蛋白，护肝药处理后，腹胀不适症缓解。4 年来，患者反复出现腹胀，多次就诊于同德医院，给予给予利尿药，白蛋白，护肝药处理。5 天前，患者出现腹胀较前加重，腹围进行性增大，自己口服利尿药后，仍感腹胀不适，自诉发热，体温未测，伴随症状性质同前。为进一步治疗，今日来我院门诊，拟“肝炎肝硬化”收院。单词：肝硬化：hepatic cirrhosis腹水：ascites蜘蛛痔：ser nevi肥胖：obesity白蛋白：albumin：hypersplenism脾功能叶酸：foli