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病历摘要:男性患者,23岁。因受凉1周前出现眼睑及双下肢浮肿伴全身不适,乏力。无腰痛及尿路刺激症状,来院治疗。体检:T36.2℃,P82次/分,BP13.3/9.33kPa,神志清、双眼睑轻度浮肿,咽红,心肺(一),肝脾不大,左肾区叩击痛(+)双下肢凹陷性水肿。化验:Hb135g/L,WBC4.7×10~9/L,N33%,L37％,血沉23mm/h,血尿素氮16.8mg/dl,肌酐6mmol/L,二氧化碳结合力17.7mmol/L,血总蛋白40g/L,白蛋白22g/L球蛋白18g/L,胆固醇3.29mmol/L,甘油三脂0.825mmol/L,尿蛋白+++,24小时尿蛋白总量2g入院诊断原发性肾小球肾病,给予青霉素、强的松潘生丁、环磷酰胺等,治疗1月后浮肿消退,尿蛋白
Medical record summary: male patient, 23 years old. 1 week ago due to cold eyelid and lower extremity edema with general malaise, fatigue. No back pain and urinary tract irritation, to hospital treatment. Physical examination: T36.2 ℃, P82 / min, BP13.3 / 9.33kPa, conscious mind, double eyelid mild edema, pharyngitis, cardiopulmonary (a), hepatosplenomegaly, percussion pain in the left kidney area Depression of both lower extremity edema. Assay: Hb135g / L, WBC4.7 × 10-9 / L, N33%, L37%, erythrocyte sedimentation rate 23mm / h, blood urea nitrogen 16.8mg / dl, creatinine 6mmol / L, carbon dioxide binding 17.7mmol / L, Protein 40g / L, Albumin 22g / L Globulin 18g / L, Cholesterol 3.29mmol / L, Triglyceride 0.825mmol / L, Urinary protein +++, 24 hours urine protein total 2g Admission diagnosis Primary renal Ball and kidney disease, given penicillin, strong pine dipyridamole, cyclophosphamide and so on, the treatment of edema disappeared after 1 month, urinary protein