CASE

Medical Number: 682786

General information

Name: Ding Zier

Age: Forty seven

Sex: Female

Race: Han

Occupation:farmer

Nationality: China

Marital status: Married

Address:jianli county，Jingzhou City,Hubei Province Date of admission: April 17, 2013 Date of record: April 17, 2013 Complainer of history: the patient herself Reliability: Reliable

Chief complaint: Intermittent low back pain for 10 years

Present illness: Ten years ago, the patient suddenly felt pain in the lower back, with hematuria , but no urinary frequency, urgency, dysuria, fever and other symptoms.After the Left kidney stones removal surgery, Patients with low back pain relief.Five years ago, patients felt intermittent low back pain with urinary frequency, urgency again, no dysuria, hematuria, fever and other symptoms, the patient didn’t treat it. 2013-02-24 reviewed the ultrasound found that "Left kidney stones" .For the sake of further treatment, then come to our hospital, outpatient revenue to "Left kidney stones" to our department.

Since the onset, the patients private prosecution spiritedness, appetite, sleep somewhat less, slightly more urination,

defecation is normal, no significant changes in physical weight. Past history

Operative history: 10 years ago,did kidney stones removal surgery.

Infectious history: No history of severe infectious disease.

Allergic history: She was not allergic to penicillin or sulfamide.

Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain.

Alimentary system: No history of regurgitation.

Genitourinary system: No history of genitourinary disease.

Hematopoietic system: No history of anemia and mucocutaneous bleeding.

Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs.

Neural system: No history of headache or dizziness.

Personal history

She was born in Jianli County and almost always lived in Jianli county. She did not go to school. Her living conditions were in general. No bad personal habits and customs.

Menstrual history: The first time when she was 16. Lasting 5 to 6 days every times and its cycle is about 33 days.

Obstetrical history: Pregnacy 4 times, 4 nature production, no abortion.

Contraceptive history: Not clear.

Family history: Her parents are still alive.

Physical examination

T 36.3℃, P 72/min, R 18/min, BP 116/76mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged. Respiratory movement was bilaterally symmetric with the frequency of 18/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 72/min. Cardiac

rhythm was not regular. No pathological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdominal. There was rebound tenderness on renal region. Liver and spleen was untouched. No masses. Shifting dullness is negative. No vascular murmurs. No edema. Physiological reflexes were existent without any pathological ones.

Head

Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.

Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.

Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.

Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.

Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.

Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.

Chest

Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.

Thorax: Symmetric bilaterally. No deformities.

Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.

Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.

Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 76/min. Cardiac rhythm was regular. No pathological murmurs.

Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There were tenderness and rebound tenderness on renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.

Extremities: No articular swelling. Free movements of all limbs. Neural system: Physiological reflexes were existent without any pathological ones.

Genitourinary system: Not examed.

Rectum: not exaned

Investigation

February 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification. Professional Examination

The ureter walking area: normal

Meatal: normal

External vaginal orifice: normal

Clitoris: normal Anus: normal

History summary

1. Patient was a farmer, female, 47 years old.

2. Intermittent low back pain for 10 years.

3. No special past history but10 years ago,did kidney stones removal surgery.

4. Physical examination showed that there were tenderness and rebound tenderness on renal region,no abnormity in lung, heart and abdominal.

5. investigation information: February 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification.

Impression: Left kidney stones

Signature: Chen Zhiqiang

第二篇：英文病例 肾内

Complete History

Name: Chen Xiaoyan Sex: female Age: 22y

Occupation: Other Nationality: Han Marital status: Married Birth Place: Jiangsu

Address: Jiangsu

Date of admission: 2010/6/2, 9:00

Date of record: 2010/6/2, 10:50

Provider: Patient herself (reliable)

Case History

Chief Complaints: Hypertension for about 2 months. Hematuria, proteinuria and serum creatinine increase for 1 week.

Present illness

The patient was checked out the BP is 160/120mmHg in the local health center in 2010/3/15. No headache, nausea and vomiting. She didn’t care. In April, She was checked out the BP is 160/120mmHg again, after using Chinese medicine, the BP could be controlled 140/80mmHg, and not using, 160/120mmHg. She was found: serum creatinine 416umol/L, urea 16.9mmol/L, uric acid 570umol/L, albumin 36g/L, Urine protein +++, red blood cell in urine +, white blood cell in urine – in The Second Peoples’ Hospital in Haimen in 2010/5/27. The test in clinic service in 2010/6/1 prompted the BP 180/120mmHg, urine protein ++++, red blood cell in urine +++, white blood cell in urine +, creatinine 468umol/L, urea 18.9mmol/L, uric acid 511umol/L, hemoglobin 106g/L. Color Doppler ultrasound prompted the right kidney 98*39*40mm, the left kidney 100*40*43mm, no extension in bilateral ureter. Levoamlodipine Maleate Tablets p.o 2.5mg qd. After falling ill, no vomiting, diarrhea, frequent micturition, urgency, urodynia, hypourocrinia. No fever, baldness, photoallergy, oral ulcer, arthralgia. No especial drug use.

General status normal. Spirit, sleep, appetite normal. Stool, urine normal. No obviously change in weight.

Past Medical History

Chronic disease history: The patient was found hypertension in 2010/3/15, the maxlmum was 180/120mmHg. No CHD or diabetes.

Operation and traumatic history: No history of operation or trauma.

Infection history: No history of tuberculosis or hepatitis.

Allergic history: No allergic history to drugs.

Blood Transfusion history: No blood transfusion history.

Review of System

Respiratory system: No history of cough, expectoration, hemoptysis, ague, fever or dyspnea.

Circulation system: No history of edema or oliguria.

Digestive system: No history of sour regurgitation, belching, nausea, vomiting, abdominal, abdominal pain, constipation, diarrhea, hemaptysis, melena, hematochezia or jaundice.

Urinary system: please refer to present illness.

Hematopoietic system: No history of acratia, dizziness, gingival bleeding, nasal bleeding, subcutaneous bleeding or ostealgia.

Endocrine system: No history of appetite change, sweating, chilly excessive thirst, polyuria, hands tremor, character alternation, obesity, emaciation, hair change, pig-mentation or amenorrhea.

Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint deformity, muscle pain or myophagism.

Neural system: No history of dizziness ,headache, vertigo, in-somnia, disturbance of consciousness, tremor, convulsion, paralysis or abnormal sensation.

Personal History

Born and grow up in Jiangsu. No smoking and drinking. No drug allergic history. No exposure history to epidemic area of infectious disease.

Marital History

Not married

Menstrual history

15 5-7/28-32, no dysmenorrhea

Family History

His parents are living and well. No inherited disease or infection disease in his family.

Physical Examination

T: 36.7℃, P: 80/min, R: 20/min, BP: 140/80mmHg.

Natural good erect posture. Well developed. Moderate nourished. Natural facial expression. Clear and cooperative in mentality. Regular respirations. No jaundice or rashes. No cyanosis and bruises. No liver palm or spider angioma. No enlarged lymph nodes. The shape of head is normal. No sclera jaundice. No edema in eye-lips, no ptosis, no congestion. The pupils are round and equal, reactive well to light and accommodation. Hearing good in both ears. No abnormal pinnae. The external canals are clear without pus. No tenderness over the mastoids. The nose showed no deformity. No discharge. There is no deviation of the septum. No tenderness over the sinuses. The lips are red, the tongue is normal. No injection on the pharynx. The tonsils are not enlarged. The neck is supple. The thyroid is not enlarged. The trachea is in the middle line. Contour is normal. No sternum tenderness. Lungs field clear to percussion without dullness or hyper-resonance. Breathing sounds are clear without pathological sounds or rales. No abnormal pulsation an uplift in precordial region. The heart percussed normal in size. Heartbeat 80. Abdomen is flat, No

tenderness. No distension. No visible peristalsis. No rigidity. No mass palpable. Liver and spleen are not palpable. Shifting dullness (-). Bowl sounds normal. No joint disease. Muscle strength normal. No abnormal motion. Neural system (-).

Special Procedures

The Second Peoples’ Hospital in Haimen in 2010/5/27: serum creatinine 416umol/L, urea 16.9mmol/L, uric acid 570umol/L, albumin 36g/L, Urine protein +++, red blood cell in urine +, white blood cell in urine –.

The test in clinic service in 2010/6/1: BP 180/120mmHg, urine protein ++++, red blood cell in urine +++, white blood cell in urine +, creatinine 468umol/L, urea 18.9mmol/L, uric acid 511umol/L, hemoglobin 106g/L. Color Doppler ultrasound prompted the right kidney 98*39*40mm, the left kidney 100*40*43mm, no extension in bilateral ureter.

Features of case history

Chen Xiaoyan, female, 22y.

Hypertension for about 2 months. Hematuria, proteinuria and serum creatinine increase for 1 week.

PE: T 36.7℃, P 80/min, R 20/min, BP140/80mmHg. Superficial nodes were not palpable. Normal vision. Lung normal. Flat abdomen, Tenderness (-), rebound tenderness (-).Liver and spleen are not palpable. Shifting dullness (-). Bowl sounds normal.

Special Procedures: The Second Peoples’ Hospital in Haimen in 2010/5/27: serum creatinine 416umol/L, urea 16.9mmol/L, uric acid 570umol/L, albumin 36g/L, Urine protein +++, red blood cell in urine +, white blood cell in urine –. The test in clinic service in 2010/6/1: BP 180/120mmHg, urine protein ++++, red blood cell in urine +++, white blood cell in urine +, creatinine 468umol/L, urea 18.9mmol/L, uric acid 511umol/L, hemoglobin 106g/L. Color Doppler ultrasound prompted the right kidney 98*39*40mm, the left kidney 100*40*43mm, no extension in bilateral ureter.

Diagnosis

CKD, stage 5

Renal Hypertension

signature： Sun

0356169