肾病综合征英文病历.docx

1、ADMISSION NOTE Name:XxxGender: maleAge: 16Marital Status: unmarriedOccupation: studentHome Address:Birth Place:Race: HanDate of Admission: 2011-8-31Date of Record: 2011-8-31Source of History: Himself & ParentsReliability: reliableChief Complaint (CC): Transient edema of both legs, edema of both eyel

2、id for 1monthHistory of Present Illness (HPI): March 2011, Cheng developed symmetric concave edema of both legs with no cause. He denied fever, pharyngodynia, rash, gross hematuria, foamed urine and left it untreated. Symptoms relieved spontaneously 1 month later. July 2011, Cheng complained of edem

3、a of both eyelids with no cause. He found it exabated in the morning and relieved in the afternoon without any complications. August 20 th 2011, he went to the local hospital for epigastric malaise. Labs showed: BP in the normal range; WBC 5.7*10 9/L, HGB 148g/L, PLT 266*10 9/L; PRO+, BLD+; 24h-UP 3

4、g; Alb 30.3g/L, Urea 3.45mmol/, Cr 81umol/L, CHO 7.77mmol/L; ASO、RF、ESR and CRP(-); B-US of kidneys was normal. “Nephrotic Syndrome” was diagnosed and left untreated. August 23 th 2011, Cheng was transferred to our hospital. Labs showed: WBC 6.84*10 9/L, HGB 149g/L, PLT 265*10 9/L; Urine PH 6.5, PRO

5、=3.0g/L, BLD 80cells/ul, Ab.RBC% 100%; 24h-UP 5.74g; Alt 19U/L, TBil 6.6 umol/L , DBil 1.7 umol/L , Alb 27g/L, Urea 4.17mmol/, Cr 62umol/L; ANA(-). Cheng is now admitted for further diagnosis and treatment.Since the onset of symptoms, his spirit, sleep, appetite and weight have not been compromised.

6、 His stool and urine volumn is normal with foams. He denies lumbodynia, hematuria, nocturia, thamuria, urgency, odynuria. He also denies rashes, photosensitivity, alopecia, eye or mouth dryness, oral ulcers, joint swelling and tenderness, Raynauds phenomenon etc.Past Medical History (PMH):1. Denied

7、history of tuberculosis or viral hepatitis, diabetes mellitus, hypertension, endemic disease etc. Denied history of trauma, surgery, blood transfusion, intoxication etc.2. Denied food or drug Allergy.3. Denied history of long-term medication.4. Review of Systems(ROS).Head, Eyes, Ears, Nose, Throat (

8、HEENT):Head: no Headache, dizziness, lightheadedness, head injury;Eyes: excellent visual acuity andvisual fields intact, no double or blurred vision, no flashing lights, pain, or redness, no excessive tearing, no history of glaucoma, cataracts;Ears: normal hearing,no tinnitus or vertigo, earaches, i

9、nfection,discharge;Nose and sinuses: no nasalstuffiness, discharge, or itching,nosebleeds; nosinus tenderness;Throat (or mouth and pharynx): no bleedinggums; good dental condition; no sore tongue or dry mouth; no frequent sore throats or hoarseness;Respiratory system: no chronic Cough, sputum, no he

10、moptysis, dyspnea, wheezing, chest pain, fever, or night sweet.Circulatory systemCardiovascular system:no palpitations, chest pain or discomfort, dyspnea, cyanosis, orthopnea, paroxysmal nocturnal dyspnea, lower extremities edema, syncope, no history of high blood pressure, or rheumatic fever,heart

11、murmurs;Peripheral vascular system: no intermittent claudication, leg cramps; no varicoseveins, past clots in the veins; no regional swelling, rednessor tenderness;Gastrointestinal system: noanorexia,trouble swallowing, heartburn, excessive belching, nausea, vomiting, hematemesis, abdominal pain/dis

12、tension, constipation, no change of bowelmovements, stool colorand size, no change in bowel habits, no pain withdefecation, rectal bleeding , hemorrhoids, no jaundice or itching.Urinary system: no frequency and urgency, or odynuria, no incontinence or dysuria, no kidney orflank pain, hematuria, pyur

13、ia, chyluria, polyuria or oliguria, anuria, nocturia. no history of kidney stones, urinary infections, ureteral colic, suprapubic pain.Male Genital system: no hernias; no dischargefrom or sores on the penis; no testicularpain or masses; no scrotal pain or swelling.Hematologic system: no pallor, dizz

14、iness, fatigue; no easy bruising or bleeding; no past transfusions and transfusion reactions.Endocrine system: no developmental malformations, thin in build, medium stature; no excessive thirst or hunger, heat or cold intolerance, excessive sweating, tremor; no polydipsia, polyphagia, polyuria; no a

15、bnormal pigmentation, abnormal hair distribution. no history of diabetes, hyperthyroidism;Musculoskeletal system: no muscle or joint swelling, warmth, redness,pain, stiffness, weakness, or limitation of motion or activity, no muscle atrophy, or joint/vertebral deformity, no history of trauma, arthri

16、tis, gout.Neurologic system: no changes in mood, speech; no changes in orientation, attention, memory, insight, or judgment; no headache, dizziness, fainting, vertigo, blackouts, weakness; seizures; noparalysis and muscular atrophy; no numbness or loss of sensation, tingling or “pins and needles”; n

17、otremors or other involuntary movements.Psychiatric state: no depression, anxiety, nervousness, tension, elation; no disorientation, delirium, hallucination; no history of psychiatric disorder, orsuicide attempts.Personal HistoryBirth history: full term, uncomplicated vaginal delivery; no sign of ne

18、onatal distress.Feeding history: good appetite and not picky at food.Developmental history: mental and physical development equivalent to boys of the same age.Immunization: standard immunization according to local plan;Life style: born and raised in the same place; he traveled to GuiLin on July 2011

19、 before symptoms appeared. denied history of accessing infectious source; denied history of radiation, intoxication; Denied history of cigarette smoking , illicit drug use or alcohol consumption.Family History (FHx)1. Both parents healthy and robust. Denied similar conditions among any family member

20、s;2. Denied history of Infectious disease among family members, such as hepatitis, tuberculosis, STD etc.3. Denied familial history of complex disease with a hereditary trend, such as HTN, DM, CAD, elevated cholesterol level, stroke, cancer, arthritis, asthma, headache, seizure, mental illness, alle

21、rgies etcPHYSICAL EXAMINATIONT 36.9 HR 82 bpm RR 20/min BP 125/65mmHg Ht 178.0cm Wt 66.5kg BMI 21kg/m2 eGFR(EPI) 139.62ml/minGeneral survey: good general state of health, no sign of distress of any kind. Medium height, relatively thin in build, sexual development not inspected.Fully conscious and al

22、ert, fairly clear articulation and good communication.Walk into the room, normal gait, active body positon. Good cooperation throughout physical.Skin: normal color, no significant sweating in extremities, normal general temperature, normal texture and flexibility. No skin lesions of any kind. No pre

23、ssure sores, crepitus. Normal hairquantity, distribution and texture. Normal nailscolor, shape, no lesions;Lymph nodes: no palpable superficial lymph nodes;HEENT(Head, eye, ear, nose, throat):Head: normal hairquantity, distribution, texture, no hair loss patches; no scaliness, lumps, nevus in scalp;

24、 normal skullsize, contour, no deformity, no tenderness; normal face skin, no stiffness in facial expression, no asymmetry, no facial involuntary movements;Eye: symmetric concave edema of both eyelids, visual fields intact; normal position and alignment of the eyes, no exophthalmos, enophthalmos. No

25、 scant or excessive eyebrows. Normal and symmetrical width of palpebral fissure, or lesion, normal eyelashes, no ptosis; normal lacrimal apparatus and nasolacrimal duct, no swelling nor excessive tearing or dryness; no chemosis, bleeding or follicles in bulbar or palpebral conjunctiva; no jaundice o

26、f sclerae; normal cornea and lenswith no opacity; normal iris; bilateral symmetrical round pupils, 3mm in diameter, the direct light reaction, the consensual reaction, near reaction-convergence & accommodation all intact; conjugate movement in 6 directions intact, convergence intact, nonystagmus, or

27、 lid lag;Ear: normal auditory acuity; Rinne test (-), Weber test (-); normal auricle, no deformity or pain; normal external auditory canal with no occlusion or discharge; eardrum intact; no mastoid tenderness;Nose: no deformity or asymmetry in contour, no saddle nose; no nasal ale flap; central sept

28、um with no sign of inflammation or perforation, epistaxis; normal turbinate; unobstructed nasal cavity and normal pink mucosa, with no ulcers or polyps, bleeding or purulent discharge; no nasal sinus tenderness;Mouth: pink nourished lips with no lesions; pink wet oral mucosa with no ulcers or white

29、patches, nodules; pink healthy gums without swelling, atrophy, bleeding, pyorrhea, gumboil, lead line or ulceration; normal teeth;normal the roof and floor of the mouth; normal the tongue color and texture, symmetrical protrusion, no ulceration or nodules, no atrophy or fasciculation; normal and sym

30、metrical soft palate movement, central uvula, no tonsillar enlargement or exudate, ulceration; no hoarseness; no abnormal oral odor.Neck: normal carotid artery pulsation without murmur, no jugular veindistension; trachea in midline position; no thyroid gland enlargement, bilaterally symmetrical, no

31、palpable nodule. no arterial thrill or murmur; no limitation of motion, rigidity & stiffness; no lumps, or tenderness;Thorax：symmetrical chest wall with no skin lesion, edemaor crepitus; normal symmetrical breasts, no palpable mass or nipple discharge;Pulmonary:Inspection: regular respiration at a r

32、ate of 18/min, no sign of distress. No three concave sign. no abnormal retraction of lower interspaces during inspiration, no local lag or impairment in respiratory movement;Palpation: symmetrical chest expansion, and tactile fremitus, no pleural friction fremitus;Percussion: symmetrical resonance o

33、ver all pulmonary field. No hyperresonance or dullness;Auscultation: clear breath sound without crackles, rhonchi, or wheezes. Symmetrical Transmitted voice sound. No pleural friction rub.Heart:Inspection(tangential): no abnormal precordial bulge, point of apical impulse invisible;Palpation: point o

34、f apical impulse at 5th intercostal space, right at left mid-clavicular line. No thrills;Percussion: span of heart dullness.Right(cm)Intercostal spaceLeft(cm)1.5II2.52III4.02IV6.0V7.5Distance from mid-clavicular line to mid-sternal line is 7.5 cmAuscultation: HR 82bpm, regular, normal heart sound wi

35、th no heart murmur or adventitious sound. No pericardial friction rub.Peripheral vascular system: bilateral symmetrical, regular, forceful radial, femoral, dorsalispedis pulse; normal venous pattern with no prominence or varicosity; no pistol shot sound, Duroziez, capillary pulsation sign, Corrigans

36、 sign or deMussets sign;Abdomen:Inspection: normal skin with no lesions, scar, striae or dilated veins. No umbilicus herniation. Flat abdomen, no abnormalbulge, depression or scaphoid belly, no peristalsis, gastric/ intestinal pattern or pulsation.Auscultation: normal bowel sounds, 3/min. no bruits

37、over aorta, renal arteries, iliac arteries, femoral arteries. No Friction rubs over spleen or liver. No Succusion splash.Percussion: generalized tympanic sound. Vertical span of liver Dullness:7cm in the right midclavicular line, 4 cm in midsternal line.No percussion pain of spleen, liver, or kidney

38、. No shifting dullness.Palpation: soft without guard, tenderness or rebound tenderness, no palpable mass. Liver, gallbladder, spleen not palpable under costal margin, Murphys sign(-). Kidney not palpable. No tenderness over ureter points. No tenderness or rebound tenderness over Mcburney point. Flui

39、d wave(-) ;Rectal and Genitalia: not examined.Extremities and Musculoskeletal: symmetrical bilateral lower extremities concave edema. no deformity or limitation in range of motion or increased mobility, no redness, warmth, swelling, tendernessin joints such as: The temporomandibular joint, shoulder,

40、 elbow, wrist and hand, hip, knee and lower leg, the ankle and foot joints and the spine. No audible or palpable crunching during movement of tendons or ligaments.No skin lesions, no muscular atrophy, stunt tenderness in bilateral biceps brachii and quadriceps femoris.Neurologic: mental status and c

41、ranial nerves are normal. Motor system: no involuntary movement; no muscular atrophy or hypertrophy and normal muscle tone in all four limbs. Sensory system: normal superficial and deep sensation.Reflexes: physiologic reflex (-);pathologic reflex (-). Meningeal signs (-).LABORATORIES AND IMAGING STU

42、DIESAugust 20 th 2011, local hospital: BP in the normal range; WBC 5.7*10 9/L, HGB 148g/L, PLT 266*10 9/L; PRO+, BLD+; 24h-UP 3g; Alb 30.3g/L, Urea 3.45mmol/, Cr 81umol/L, CHO 7.77mmol/L; ASO、RF、ESR and CRP(-); B-US of kidneys was normal.August 23 th 2011, our hospital: WBC 6.84*10 9/L, HGB 149g/L,

43、PLT 265*10 9/L; Urine PH 6.5, PRO=3.0g/L, BLD 80cells/ul, Ab.RBC% 100%; 24h-UP 5.74g; Alt 19U/L, TBil 6.6 umol/L , DBil 1.7 umol/L , Alb 27g/L, Urea 4.17mmol/, Cr 62umol/L, CHO 7.77mmol/L; ANA(-).SUMMARYXxx, male, 16 y/o, is admitted for “transient edema of both legs, edema of both eyelid for 1month

44、”. March 2011, Cheng developed symmetric concave edema of both legs. Symptoms relieved spontaneously 1 month later. July 2011, Cheng complained of edema of both eyelid which was exabated in the morning and relieved in the afternoon. August 20 th 2011, labs showed: BP in the normal range; WBC 5.7*10

45、9/L, HGB 148g/L; PRO+, BLD+; 24h-UP 3g; Alb 30.3g/L, Urea 3.45mmol/, Cr 81umol/L, CHO 7.77mmol/L; ASO、RF、ESR and CRP(-); B-US of kidneys was normal. “Nephrotic Syndrome” was diagnosed and left untreated. August 23 th 2011, labs showed: WBC 6.84*10 9/L, HGB 149g/L; Urine PRO=3.0g/L, BLD 80cells/ul, A

46、b.RBC% 100%; 24h-UP 5.74g; TBil 6.6 umol/L , DBil 1.7 umol/L , Alb 27g/L, Urea 4.17mmol/, Cr 62umol/L; ANA(-). Foamed urine was also found. PMH, PHx and FHx are significant. PE: BP 125/65mmHg; eGFR(EPI) 139.62ml/min; symmetrical concave edema of both eyelids.Impression: Nephrotic SyndromeSignature:A

47、SSESSMENT &PLANI. Characteristics of the patient1. 16 y/o, male, chronic course, acute onset.2. Transient edema of both legs, edema of both eyelid for 1month.3. March 2011, Cheng developed symmetric concave edema of both legs. Symptoms relieved spontaneously 1 month later. July 2011, Cheng complaine

48、d of edema of both eyelids. August 20 th 2011, labs showed: HGB 148g/L; PRO+, BLD+; 24h-UP 3g; Alb 30.3g/L, Urea 3.45mmol/, Cr 81umol/L, CHO 7.77mmol/L; ASO、RF、ESR and CRP(-); B-US of kidneys was normal. “Nephrotic Syndrome” was diagnosed and left untreated. Foamed urine was also found.4. PE: BP 125

49、/65mmHg; eGFR(EPI) 139.62ml/min; symmetrical concave edema of both eyelids.5. Labs: August 23 th 2011, labs showed: HGB 149g/L; Urine PRO=3.0g/L, BLD 80cells/ul, Ab.RBC% 100%; 24h-UP 5.74g; TBil 6.6 umol/L , DBil 1.7 umol/L , Alb 27g/L, Urea 4.17mmol/, Cr 62umol/L; ANA(-).6. PMH, PHx and FHx are ins

50、ignificant.II. Assessment Cheng is a young male who has a chronic course and is on an acute onset. His manifestations are heavy proteinuria(PRO=3.0g/L, 24h-UP 5.74g), nearly hypoalbumine(Alb 30.3g/L), hypercholesterolemia(CHO 7.77mmol/L), symmetrical concave edema of both eyelids, mild hematuria(BLD

51、 80cells/ul, Ab.RBC% 100%). Thus the diagnosis of NS is confirmed. Differential diagnosis of the etiological factors includes:Firstly we should exclude the secondary and inherited glomerular diseases:1. Inherited glomerular disease: Alports Syndrome: Classically, patients may develop hematuria, thin

52、ning and splitting of the GBMs, mild proteinuria (12g/24h), and chronic glomerulosclerosis, leading to renal failure in association with sensorineural deafness. Some patients develop lenticonus of the anterior lens capsule and, rarely, mental retardation or leiomyomatosis. Cheng has severe proteinur

53、ia and dosnt complain of lesions of ears or eyes. And he is good at his study and denies similar conditions among any family members. Thus we can exclude it immediately. Fabrys Disease: Classically, it presents in childhood in males with multi-organ involvement. The nephropathy typically presents in

54、 the third decade as mild to moderate proteinuria, sometimes with microscopic hematuria or nephrotic syndrome. Chengs manifestations are only related with kidneys and he dinies similar conditions among any family members. Thus it can be excluded.2. Infection: Hepatitis B and C, syphilis, malaria, sc

55、histosomiasis, leprosy, filariasis may be involved. Typically, hepatitis B infected patients only present with microscopic hematuria, nonnephrotic or nephrotic-range proteinuria, and hypertension. Patients with hepatitis C often present with cryoglobulinemia and nephrotic syndrome, microscopic hemat

56、uria, abnormal liver function tests, depressed C3 levels, anti-HCV antibodies, and viral RNA in the blood. Cheng denies history of accessing infectious source and viral hepatitis. We may further order a infectious agents screening to exclude it.3. Autoimmune diseases: Lupus Nephritis: The most commo

57、n clinical sign of renal disease is proteinuria, but hematuria, hypertension, varying degrees of renal failure, and an active urine sediment with red blood cell casts can all be present. The extrarenal manifestations of lupus are important and varied. Cheng denies lesions of other organs and his ANA

58、 is negative. We may further order a immune agents screening and renal biopsy if necessary. ANCA Small Vessel Vasculitis: Wegeners granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome belong to this group. Patients have serum ANCA; the antibodies are of two types, anti-proteinase 3 (PR3) or anti-myeloperoxidase (MPO). Classically, patients may present with fever, purulent rhinorrhea, nasal ulcers, sinus pain, polyarthralgias/arthritis, cough, hemoptysis, shortness of breath, microscopic hematuria, and