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患者,杨某,女性,52岁,农民,住院号2560。患者因逐渐加重尿频、尿急、尿痛四年,多次在其它医院抗炎治疗无效,于86年8月28日以“尿路感染”收住我院内科治疗。入院时24小时尿次达50次以上,每次仅10—20毫升不等,因抗炎无效给行肾盂静脉造影后于86年9月11日转我科治疗。既往无结核病史。转科时体温38.5℃,脉搏92次/分,呼吸21次/分,血压100/80mmHg。消瘦体质,慢性病容,卧床不起,生活不能自理。皮肤粘膜无黄染,浅表淋巴结不肿大,头颅五官及颈部无异常,心肺(一),腹部无异常,膀胱区不充盈,但压痛明显。双肾未触及,右肾区轻度叩击痛,双输尿管走行区无压痛,肛门、外生殖器无异常发现。
Patient, Yang, female, 52 years old, farmer, hospital number 2560. Patients gradually increased urinary frequency, urgency, dysuria four years, many times in other hospitals anti-inflammatory treatment ineffective, on August 28, 86 to “urinary tract infection” admitted to our hospital medical treatment. Admission 24 hours urinary times of 50 times or more, each time only 10-20 ml, due to anti-inflammatory ineffective to line after renal pelvis and vein imaging in September 11, 86 turn my treatment. No past history of tuberculosis. Turn subjects when body temperature 38.5 ℃, pulse 92 beats / min, breathing 21 beats / min, blood pressure 100 / 80mmHg. Weight-loss physique, chronic illness, bedridden, life can not take care of themselves. Skin and mucosa without yellow dye, superficial lymph nodes are not enlarged, facial features and neck no abnormalities, cardiopulmonary (a), no abnormal abdomen, bladder area is not full, but tenderness significantly. Kidney not touched, the right renal area mild percussion pain, ureteral walking area without tenderness, anus, genitals no abnormal findings.