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
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.
3.Impression:
Chronic kidney disease with uremia
4.Plans:
(1) Diagnostic plan:
1) Collect 24-hour urine to estimate CCR and daily protein loss
2) Check Ca, P, Mg, Cl, uric acid, albumin, and iPTH
3) Arrange renal echo to evaluate the morphology and sizes of kidneys
4) Follow up BUN, Cr, Na, K and ABG
(2) Therapeutic plan:
1) Adequately infuse normal saline and record intake/output, avoid over-hydration
2) Administer Promeran for symptomatic relief
3) Arrange emergent hemodialysis (置入雙腔導管並安排緊急血液透析)
if the patient agrees
4) Prepare for renal replacement therapy (AV shunt creation or Tenckhoff catheter
implantation) after the patient makes a decision to receive hemodialysis or
peritoneal dialysis
(3) Educational plan:
1) 告知病人洗腎的 indication，包括頑固性高血鉀、代謝性酸血症，體液超負
荷併發肺水腫，尿毒症候群及無法忍受的尿毒症狀等
2) 給予血液透析及腹膜透析之衛教
Case 10: Urinary tract infection or acute pyelonephritis
1.Chief complaint:
Intermittent fever for 3 days
2.Present illness
This 36-year-old woman healthy before admission had: intermittent fever (up to
39.2 °C) for about 3 days; dysuria with burning sensation and urinary frequency for
about 5 days; general discomfort; right flank soreness. She who denied headache,
rhinorrhea, sore throat, chest discomfort, dyspnea, cough, sputum production,
abdominal pain, or diarrhea visited a local clinic, and took some medicine which
relieved no symptoms. Because of intermittent fever, she came to our emergency
department.
On physical examination at ER, the temperature was 38.2 °C; the blood pressure,
128/78 mm Hg; the pulse, 77 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, normal tympany, and no palpation tenderness of
abdominal and suprapubic region; knocking pain, over the right costovertebral angle.
The laboratory examination evidenced left shift leukocytosis and high CRP. White
and red blood cells urine was positive. For acute right pyelonephritis, she was
admitted for further appraisement and administration.
3.Impression:
Acute pyelonephritis, right
4.Plans:
(1) Diagnostic plan:
1) Collect blood and urine specimen for microbial cultures (急診已做)
2) Arrange renal echo for image study
(2) Therapeutic plan:
1) Administer empirical antibiotics and adjust it according to the result of cultures
2) Adequately infuse normal saline to increase the urine amount
3) Repeat urinalysis to evaluate the effect of treatment several days later
(3) Educational plan:
1) Encourage her to drink more water and avoid suppressing the urination
2) Educate about local hygiene in the perineal area