Имя: Mr. Wang
Возраст: 68 лет
Диагноз: 1. Хроническая почечная недостаточность 2. Почечная анемия 3. Гипертония 2 степени 4. Кистоз печени 5. Кистоз почек
Дата госпитализации: 9 сентября 2010 г.
Длительность лечения: 35 дней
The physical examination Mr. Wang had 4 years ago found: BUN, BCr and UA were above normal value, the urine protein was positive. The B ultrasound of the kidneys found: Cysts and hyrdops in both kidneys. The examination of the kidneys shows abnormalities including renal insufficiency. Mr. Wang has thalassemia minor; other symptoms include mild anemia, edema, lumbago, oliguria and hematuria. One month ago, there was pain felt in the right waist, with weakness; there was no nausea or vomiting.
The blood routine: RBC4.06 10*12/l, HGB115g/l, others within normal range. The urine routine: urine protein ++, others are normal. The renal function: BUN 45mg/dl, CRE 477.36umol/l. UA: 9.4 mg/dl; K+ 5.2mmol/L. The results showed that Mr. Wang’s condition was more severe than before. His condition continued to worsen which naturally worried his family. After these examinations were given, Mr. Wang came to our medical center accompanied by some of his family members.
Routine urine test: HGB89g/L,RBC3.10,HCT26.9%, others within normal range.. Urine routine: traces of albumin, granular casts 0-1/HP, others within normal range.. Renal function: BUN26.61mmol/L, UA465ummol/L, CREA489ummol, others within normal range. Coagulation function: FIB4.59g/L, the liver function was normal.
The B ultrasound showed: multiple cysts in the liver, diffuse lesions in both kidneys, there is a major possibility of kidney damage, with multiple cysts. The ultrasound of the bilateral carotid artery and vertebral artery showed: bilateral carotid artery atherosclerosis, large amounts of plaque, with no obvious stenosis. The ultrasound of the pelvic cavity showed: the prostate gland is slightly enlarged; the echo wasn’t uniform, hyperplasia. The ultrasound of the heart showed: mild incompetency of the valvula bicuspidalis, the left ventricle systolic functioning is normal.
Mr. Wang received all of the relevant examinations and was diagnosed with 1.Chronic renal insufficiency renal anemia 2. Hypertension level 2-extremely high-risk 3. Multiple hepatic cysts 4. Multiple renal cystic disease. Mr. Wang was given treatment in order to expand the blood vessels and improve the blood circulation, improve the renal functioning, regulate his blood pressure, adjust the condition of the body, and correct his anemia.
Mr. Wang’s blood pressure has been brought under control. The urine routine: protein 1+. The renal function: BUN 19.65mmol/L, CRE 471umol/l, Uric Acid: 348umol/L. The blood routine: HGB103g/L, RBC3.42, HCT31.7%. The electrolytes, liver functioning, plasma protein and blood lipid levels are normal. The coagulation function: FIB4.19, others within normal range. Mr. Wang is now in a better mental state. The general fatigue symptoms have disappeared. The lumbago has also disappeared. The frequency of his nocturia has decreased. The color of the senile plaques has become shallow. The anemia is not as severe.The amount of coughing has decreased. Mr. Wang’s renal functioning has improved.