腎臟內科標準病歷範本
Case 1: Acute kidney injury
1.Chief complaint:
Decreased urine amount for 5 days
2.Present illness
This 52-year-old man of antecedent HTN and gout without regular follow-up is a laborer and sweats much when working. He took some analgesics from a pharmacy last week due to the gouty arthritis attack. At this time, he suffered decreased urine for about 5 days, beside mild generalized edema, mild dyspnea and dry cough, and denied fever, chills, headache, dizziness, sore throat, rhinorrhea, chest pain, abdominal pain, back pain, diarrhea, constipation, dysuria or hematuria. Because of the above symptoms, he visited our emergency department.
On physical examination at ER, the temperature was 36.1°C; the blood pressure, 142/86 mm Hg; the pulse, 88 beats/minute; the respiratory rate 24 breaths/minute; the oxygen saturation, 97%, while the patient was breathing ambient air. The breath sounds were slight rales. Rapid and mildly deep breaths were rendered. The abdomen was flat, with normo-active sounds, normal tympany, and no palpation tenderness. The bilateral costovertebral angles had no knocking pain. The laboratory examination expressed mild leukocytosis, elevated BUN and creatinine, and hyponatremia. The serum potassium levels were within normal limits, but the arterial blood gas manifested mild metabolic acidosis with partial respiratory compensation. Red blood cells and white blood cells urine was positive. For acute kidney injury, he was admitted for further appraisement and administration.
3.Impression:
一、Acute kidney injury, cause:
(1) Dehydration
(2) NSAIDs related
(3) Suspect gouty nephropathy
二、Probable urinary tract infection
4.Plans:
(1) Diagnostic plan:
1) Check Ca, P, Mg, Cl, Albumin, uric acid
2) Arrange renal echo to see the morphology of kidneys and to rule out post-renal
obstruction
3) Collect blood (急診已做) and urine specimen for microbial cultures
4) Follow up BUN, Cr, Na, K, ABG
(2) Therapeutic plan:
1) Adequately infuse normal saline to replace the depleted volume
2) Record intake and output and avoid fluid overload
3) Avoid nephrotoxic agents, such as NSAIDs or Aminoglycoside
4) Administer empirical antibiotics and adjust it according to the result of cultures
(3) Educational plan:
1) Encourage him to drink water, especially when sweating much
2) Educate about avoiding over-the-counter drugs abuse
Case 2: Acute pulmonary edema
1.Chief complaint: Shortness of breath for 2 weeks
2.Present illness
This 64-year-old male with diabetes mellitus and hypertension and without regular control presented to our emergency department, beside progressive shortness of breath for 2 weeks.
Two months before this presentation, edema developed in both lower legs. The patient visited a clinic, and was diuretics-treated and better. Approximately 2 weeks prior to this admission, he began to experience dyspnea and dry cough and got worse when he exercised or lay down, and relieved slightly when he sat up. The symptoms were decreased urine-associated. His appetite was mildly impaired but he liked water and juice. Otherwise, no chest tightness, palpitation, fever, chills, or sputum was projected. He denied applying analgesics or herbal medicine.
At ER, he was dyspneic with the respiratory rate 33/min, blood pressure 190/100 mmHg, heart rate 90 bpm and SpO2 92%. Chest X-ray certified cardiomegaly and infiltration of bilateral lung fields and blunting of bilateral costophrenic angles. The complete blood count was relatively normal, except anemia (hemoglobin 7.3 g/dL). Biochemistry data disclosed BUN 98 mg/dL, creatinine 7.6 mg/dL, Na 125 meq/L, and K 5.7 meq/L; arterial blood gas, pH 7.24, PaCO2 20 mm Hg, and HCO3- 10 mEq/L. The 3-hour emergent hemodialysis with ultrafiltrate 3 ml/kg was via the right femoral double-lumen catheter at ER. Then the patient was admitted for further appraisement and administration.
3. Impression:
Acute pulmonary edema (differential diagnosis: end-stage renal disease, congestive heart failure)
4. Plans:
(1)Diagnostic plan：
- Arrange renal echo for kidney size and morphology and rule out post-renal obstruction
- Arrange cardiac echo for heart function survey
- Check urine analysis
- Check 24hr urine for CCr and total protein
- Check serum albumin, Ca, P
(2)Therapeutic plan：
- Record I/O and body weight
- Arrange regular hemodialysis (qW1,3,5 or qW2,4,6)
(3)Educational plan：
- Water restriction <1500mL/day
- Diet: low salt diet Na < 3g/day, low P, low K diet
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Case 3: Adrenal tumor
1. Chief complaint: General weakness for weeks
2.Present illness:
This 22-year-old college student, healthy except with high blood pressure in a physical check-up one year ago (SBP about 160-170 mmHg), paid no attention to the high blood pressure because of no symptom. However, he occasionally had general weakness and headache in recent weeks, despite a good appetite, and visited our ER due to acute-onset epigastric pain associated with nausea and vomiting after dinner last night. The abdominal pain was relieved after vomiting. Otherwise, no diarrhea or constipation was observed. At ER, the blood pressure was 177/110 mmHg; HR 73/min. Lab data discovered hypokalemia (K: 1.87 meq/L) and normal Cr (0.95 mg/dL); CT for abdominal pain, no abnormality except a left adrenal tumor. He denied flush, sweating, palpitation, or weight loss before admitted for further study.
3. Impression:
(1) Hypokalemia, suspect urine K loss but transient K shift into cells can not be ruled out
(2)Hypertension, suspect secondary hypertension (ex: hyperaldosteronism, pheochromocytoma…)
(3) Left adrenal tumor (incidentaloma), nature to be determined
4. Plans
(1)Diagnostic plan：
- Check spot urine TTKG or 24 hr urine K
- Check vein CO2
- Check plasma aldosterone and plasma renin activity (PRA) and calculate aldosterone-renin ratio (ARR)
- Check 24 hr urine VMA and catecholamines
- Check thyroid hormone (TSH, free T4)
(2)Therapeutic plan：
- K replacement: KCL 20meq in normal saline 500mL ivdrip 80mL/hr and Slow K 2# po TID
- Control blood pressure gradually with antihypertensives (First use alpha-blockers, non-dihydropyridine calcium channel blockers such as verapamil slow-release, or direct vasodilators such as hydralazine; avoid ACEI/ARB, NSAIDS, beta-blockers, central alpha2-agnoists, dihydropyridine calcium channel antagonists before above examination)
(3) Educational plan：Encourage fruit intake for oral K replacement
Case 4: CAPD-pertinent peritonitis
1. Chief complaint: Diffuse abdominal pain for 1 day
2.Present illness:
This 54-year-old female with end-stage renal disease (ESRD) secondary to diabetes mellitus (DM), on continuous ambulatory peritoneal dialysis (CAPD) for 3 months, presented to our ER, beside diffuse abdominal pain for 1 day. Her CAPD prescription was 4 exchanges of 1.5% dextrose daily. The night before this admission, she routinely exchanged the last bag of dialysate for CAPD, before which she forgot to wash her hands. About 3 a.m., she was awake for her abdomen painful, so she took some antacid and was better. This morning she exchanged her dialysate and discerned the dialysate effluent cloudy. The abdominal pain also progressed and was fever- and chills- associated, so she was brought to our ER before admitted. Throughout the course, no nausea, vomiting, or diarrhea was noted.
3. Impression
CAPD-related peritonitis, suspect touch contamination
4.Plans
(1)Diagnostic plan：
- Collect CAPD dialysate effluent for routine, Gram stain and aerobic culture before antibiotics
- Follow up CAPD dialysate effluent routine for WBC
(2)Therapeutic plan：
- Intraperitoneal (IP) antibiotics (較簡易的一日一次給藥法):
- Loading dose Cefazolin 1g and Gentamicin 16mg IP in a new bag of CAPD dislyate for 8 hours stat, then
- Maintenance dose: Cefazolin 1g and Gentamicin 32mg IP in the last bag of CAPD dialysate HS
(3)Educational plan：
- Educate the patient to wash hands before each exchange of CAPD dialysate
- Contact CAPD nurses to arrange CAPD procedure retraining for the patient
Case 5: Double-lumen catheter infection
1. Chief complaint: Fever for 1 day
2. Present illness
This 80-year-old patient on 2-week hemodialysis for end-stage renal disease secondary to chronic glomerulonephritis had fever and chills since last night and presented to our ER. The vascular access for hemodialysis was with a double-lumen catheter via the right femoral vein due to immature arteriovenous fistulas in the left forearm. During hemodialysis today, the purulent discharge from the double-lumen catheter exit site with redness and tenderness around was perceived; so were fever and chills. Thus, a culture of the purulent discharge and 2 sets of blood cultures were collected and the remarked catheter was removed after the hemodialysis. Throughout the course, no cough, abdominal pain, or dysuria was noted. No other wound except at the double-lumen catheter site was discovered.
3. Impression: Double-lumen catheter infection
4.Plans
(1)Diagnostic plan：
- Pending the wound culture and blood culture report
- Monitor vital signs and sepsis signs
(2)Therapeutic plan：
- Empiric antibiotics Oxacillin 1g iv q6h to cover Gram positive bacteria, and adjust antibiotics according to the blood culture report and clinical signs
- Double-lumen catheter insertion via left femoral vein (or jugular vein, preferred) for hemodialysis next time under strict aseptic conditions
(3)Educational plan：
- Keep the double-lumen catheter puncture site dry and clean, no not touch with hands or water
Case 6: Hematuria (of GN)
1. Chief complaint: Intermittent bloody urine for 3 months
2.Present illness:
This 33-year-old worker who had been healthy until 3 months ago was admitted for an episode of bilateral flank pain with bloody urine. He first visited another hospital where imaging study of urinary tract noticed no specific finding. The flank pain subsided but episodes of bloody urine persisted. The bloody urine exacerbated after carrying heavy objects or rigorous exercise. Otherwise, no fever, anorexia, dizziness, dysuria, hemoptysis or tarry stool passage was noted. He was referred to our hospital for further evaluation. At the outpatient section, urine analysis avowed RBC >100/HPF and protein 2+; lab data, creatinine 2.1 mg/dL with no progression (in comparison with creatinine 2.0 mg/dL 3 months before); renal ultrasonography, both kidneys with normal size and echogenicity without hydronephrosis. He was admitted for renal biopsy.
3. Impression:
Hematuria, suspect glomerulonephritis
4. Plans
(1)Diagnostic plan：
- Check uirne analysis with dysmorphic RBC ratio for differentiating lower urinary tract hematuria from glomerular hematuria
- Collect 24 hr uirne for total protein and CCr for grading proteinuria
- Check IgA, IgG, IgM, C3, C4, ANA, anti-basement membrane antibody, ANCA, Albumin, globulin, Ca
- Check Hb, Platelet, PT, APTT, bleeding time before renal biopsy
(2)Therapeutic plan：
- Add ACEI/ARB if no contraindication for chronic kidney disease with proteinuria
(3)Educational plan：
- Explain renal biopsy procedure and acquire permit
- Adequate hydration and avoid nephrotoxic agents such as NSAIDs to prevent dehydration and acute kidney injury
Case 7: Hematuria (Urolithiasis)
1.Chief complaint:
Pinkish urine for 3 days
2.Present illness
This 56-year-old man of antecedent HTN and CAD s/p PC received follow-up regularly at our clinic, noted pinkish urine for 3 days which had not existed, and recently denied: flank pain; back pain; trauma history; headache; dizziness; rhinorrhea; sore throat; chest discomfort; dyspnea, cough; sputum production; abdominal pain; diarrhea; dysuria. Because of the above aggravating symptoms, he came to our emergency department.
On physical examination at ER, the temperature was 36.8°C; the blood pressure, 138/78 mm Hg; the pulse, 82 beats/minute; the respiratory rate, 18 breaths/minute; the oxygen saturation, 100%, while the patient was breathing ambient air. The abdomen was flat, with: normo-active sounds; tympany; no palpation tenderness in the abdominal and suprapubic region. The bilateral costovertebral angles had no knocking pain. The laboratory examination evinced normal CBC. The biochemistry was also unremarkable except for mildly elevated blood sugar. The red blood cells urine was positive. For gross hematuria, he was admitted for further appraisement and administration.
3.Impression:
Gross hematuria, painless, suspect
(1) Malignancy
(2) Urolithiasis
4.Plans:
(1) Diagnostic plan:
1) Arrange renal echo for image study
2) Collect urine for cytology
3) Consult uroligist
4) Consider IVP or RP study
(2) Therapeutic plan:
1) Transamin 500 mg iv psuh Q8H
2) Hold anti-platelet agents
(3) Educational plan:
1) 鼓勵病人多喝水以增加尿量，避免blood clot阻塞泌尿道
Case 8: Nephrotic syndrome
1.Chief complaint:
Progressive generalized edema for 2 weeks
2.Present illness
This 68-year-old man of antecedent HTN with regular follow-up at our hospital has had progressive generalized edema for 2 weeks, beside shortness of breath, orthopnea and mild cough. Despite frothy urine, he denied: decreased urine amount; fever; chills; headache; dizziness; rhinorrhea; sore throat; chest discomfort; abdominal pain; diarrhea; dysuria. Because of the said aggravating symptoms, he came to our emergency department.
On physical examination at ER, the temperature was 36.1°C; the blood pressure, 148/86 mm Hg; the pulse, 92 beats/minute; the respiratory rate, 26 breaths/ minute; the oxygen saturation, 92% while the patient was breathing ambient air. Puffy eyes were perceived; so was generalized pitting edema. The breath sounds were rales and the breath pattern was mildly rapid and shallow. The abdomen was flat, with normo-active sounds, normal tympany, and no palpation tenderness. The bilateral costovertebral angles had no knocking pain. The laboratory examination exhibited mild leukocytosis and hyponatremia. Plus 3 protein urine was positive. For heavy proteinuria, probably nephrotic syndrome, he was admitted for further appraisement and administration.
3.Impression:
Heavy proteinuria, suspect nephrotic syndrome
4.Plans:
(1) Diagnostic plan:
1) Collect 24-hour urine to estimate daily protein loss
2) Arrange renal echo for image study
3) Check albumin, HbA1c and lipid profile
4) Discuss with the patient (and his family) and arrange renal biopsy if they agree
(2) Therapeutic plan:
1) Adequate diuretics use
2) Administer Albumin if indicated
3) Record body weight QD or I/O Q8H
(3) Educational plan:
1) 避免過度運動、儘量臥床休息及限制鹽份的攝取
2) 若有突然變得更喘或血痰，應小心是否有肺栓塞的可能性
Case 9: Uremia
1.Chief complaint:
General weakness and anorexia for 1 month
2.Present illness
This 56-year-old man of preceding hypertension and gout without regular follow-up is used to taking: analgesics from a pharmacy when gouty arthritis attacks; herbal medicine for health.
At this time, the general weakness and discomfort has lasted for 1 month; so has dizziness, nausea, vomiting and anorexia, beside denied: fever; chills; headache; URI symptoms; chest discomfort; dyspnea; abdominal pain; diarrhea; constipation; decreased urine amount; dysuria. He went to a local clinic 1 week ago; hence, his acute gastroenteritis was diagnosed and medicated, but the symptoms were not relieved. Because of intractable nausea and vomiting, he visited our emergency department.
On physical examination at ER, the temperature was 36.2 °C; the blood pressure, 162/92 mm Hg; the pulse, 98 beats/minute; the respiratory rate, 22 breaths/minute; the oxygen saturation, 99% while the patient was breathing ambient air. Pale skin and anemic conjunctiva were avowed; so were the clear breath sounds. The abdomen was flat, with hyperactive sounds, normal tympany, and no palpation tenderness. The legs had no pitting edema. The laboratory examination stated: severe normocytic anemia; high BUN and creatinine. Additionally, the serum sodium and potassium levels were within normal limits, but the arterial blood gas attested mild metabolic acidosis with respiratory compensation. Red blood cells urine was positive; so was mild proteinuria. For chronic kidney disease with uremia, he was admitted for further appraisement and administration.