男,78岁,急性肾盂肾炎患者尿路感染伴尿频、尿急、尿痛病例

2020-06-29 孙医生 病例网

患者于今晨起无明显诱因出现尿频、尿急、尿痛,排尿不畅,尿量及尿颜色正常,伴有发热,无寒战,无头晕,无全身酸痛,无恶心呕吐。今即来我院求治,门诊拟“尿路感染”收入住院治疗。发病来,精神、食欲稍差

[患者姓名]:
[患者年龄]:78
[性别]:男
[科室]:肾脏内科

【主诉】

尿频、尿急、尿痛伴发热1天。

【现病史】

患者于今晨起无明显诱因出现尿频、尿急、尿痛,排尿不畅,尿量及尿颜色正常,伴有发热,无寒战,无头晕,无全身酸痛,无恶心呕吐。今即来我院求治,门诊拟“尿路感染”收入住院治疗。发病来,精神、食欲稍差,大便正常,发病来体重无明显变化。

【既往史】

否认"高血压"、"糖尿病"“冠心病”等病史,否认"肝炎"、"肺结核"等传染病史,无药物及食物过敏史、无外伤手术史。无输血史。预防接种史不详。

【查体】

T:38.1℃,P:77次/分,R:20次/分,BP:116/77/mmhg。发育正常、营养中等,神志清楚、呼吸平顺,步入病房,自动体位,检查合作。全身皮肤、粘膜无黄染及出血点,浅表淋巴结无肿大。头颅、五官无畸形、巩膜无黄染、双侧瞳孔等大等圆,对光反射灵敏。口唇无紫绀、咽不红、双侧扁桃腺无红肿。颈软、无颈静脉怒张,气管居中,双侧甲状腺不肿大。胸廓对称、无畸形、语颤相等。双肺叩诊清音,听诊呼吸音清,未闻及干湿性啰音。心前区无隆起、心尖搏动位于左锁骨中线第5肋向内0.5cm处,无震颤、心界不扩大,心率77次/分、律齐,各瓣膜听诊区未闻及杂音。腹平软,肝脾肋下未触及肿大,全腹未扪及包块、无压痛及反跳痛,双肾区有击叩痛,无移动性浊音,肠鸣音正常。脊柱四肢无畸形,活动正常。生理反射存在,病理反射未引出。

【辅助检查】

尿液分析:隐血++尿蛋白+,白细胞+++。血常规、肝肾功能、电解质未见明显异常。双肾、输尿管彩超未见明显异常。

【初步诊断

急性肾盂肾炎

【鉴别诊断】

肾结石:多表现为腰痛,可伴有尿频、尿急、尿痛,血尿,此患者肾脏及输尿管彩超未见结石,不考虑。

【诊治经过】

患者入院后予完善相关检查,嘱多饮水,予头孢曲松抗感染,口服碳酸氢钠片碱化尿液治疗,治疗5天后,患者症状改善,出院改口服左氧氟沙星片治疗,嘱1周后门诊复查尿液分析。

【分析总结】

患者表现为尿频、尿急、尿痛,伴有发热,腰痛,结合尿液检查结果考虑记性肾盂肾炎诊断明显,抗生素选择三代头孢或喹诺酮类,治疗疗程推荐1-2周,出院1周后复查尿液分析。

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    2020-07-01 cnxcy
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    2020-07-01 villahu
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    2020-07-01 lfcmxl

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