Имя: Yu Han
Возраст: 38 лет
Диагноз: Хроническая почечная недостаточность, уремия
Дата госпитализации: 13 февраля 2013 г.
Длительность лечения: 28 дней
In 2004 the patient’s lower limbs suffered from petechia and she was diagnosed with purpura. She received medication for treatment. After treatment, the patient suffered from purpura regularly due to a respiratory tract infection. The purpura attacks happened every year and she went to the hospital repeatedly. The patient received hematology laboratory examination and the renal insufficiency was found in 2008. The patient received medication for treatment, but the effect was not good. The disease progressed gradually. The patient suffered from anemia and hypertension in 2012. The patient received antihypertensive drugs in the local hospital for treatment. The blood pressure was under control. Before the treatment, the patient had severe anemia, poor spirits, poor appetite and dark skin. There was slight pain in the right renal region when tapping it. There was no fever, oliguria or hematuria.
Bp: 116/72mmHg; Hr: 83/min. Ko-Yu-Jin was alert and development was normal. The nutrition was poor and she breathes naturally. She cooperated with all of the physical examination. The skin of the whole body was presented as dull yellow and had no gloss. The lymph nodes were not enlarged. The skull shape was normal. There was no edema in the eyelid. The palpebral conjunctiva was pale. Both pupils were equal in size and round, the diameter was about 2.5 mms. Both pupils had light reflex, accommodation reflex and convergence reflex. There was no purulent secretion in the ears. There was no deformity of the thorax. The back was smooth and had no nodules. The respiration sounds in both lungs were weak, with no dry or moist rales. There was no precordial bulging. The position of the apex beat was normal. The heart sounds were weak, the rhythm was regular. There was no pathologic heart murmur in the valve areas. The abdomen was flat. The liver and spleen were not palpable under the ribs and there was no pressing pain or rebound tenderness. There was no shifting dullness. The bowel sounds were normal. There was percussion pain in right renal region. There was no percussion pain or pressing pain in the left renal region. The spinal column, all four limbs and genitalia were normal. The muscle tone and muscle strength were normal. The muscle strength and muscle tone in four limbs was normal. The deep and shallow sensation was normal. The coordinated movements were normal. The abdominal reflexes were weak. Bilateral patellar tendon reflex and Achilles tendon reflex were normal. The bilateral pathology sign was negative. There were no signs of meningeal irritation. The function index of the kidney BUN33.7mmol/l, UA560umol/l, CREA962umol/l.
Yu Han received all of the relevant examinations. She was diagnosed with chronic renal insufficiency, the period of uremia. She received treatment for kidney repair, nephron reconstruction, improve renal function, control blood pressure, rectify anemia and adjust the state of the body.
The patient has a better mental state. The color of the skin is better than before. The blood pressure is stable. The renal function is obviously improved. The laboratory test shows: BUN25.57mmol/l,UA421umol/l, CREA518umol/l.