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1、Case History Report General informationnName:TannGender: malenAge: 37nMarital Status: marriednOccupation: farmernBirth Place:Gaoyou City Jiangsu ProvincenRace: HannSource of History: himselfnDate of Admission: 2015-11-21Chief Complaint n Edema of both lower limbs for 10 days.Present illnessnTen days
2、 ago,the patient developed symmetric concave edema of both lower limbs with no cause,and edema of both eyelids are not obvious ,and left it untreated. A week later, he came to our hospital for diagnosis and treatment.Present illnessnLabs showed: Blood-RT WBC 11.37*10 9/L, HGB 120g/L, PLT 280*10 9/L;
3、 Urine-RT:BLD +,RBC 27cells/ul; Urine PRO 17.35g/L;Alb 24.1g/L ;TG 2.12mmol/L,CHO 9.78mmol/L. “Nephrotic Syndrome” was diagnosed and admitted for further diagnosis and treatment.Present illnessnSince the onset of symptoms, his spirit, sleep, appetite and weight have not been compromised. His stool a
4、nd urine volume are normal with foams. He denies lumbodynia, hematuria, nocturia, thamuria, urgency, odynuria. Present illnessnHe also denies rashes, photosensitivity, alopecia, eye or mouth dryness, oral ulcers, joint swelling,cough, chest tightness, and shortness of breath, abdominal pain etc.; An
5、d he denies taking drugs before the onset of symptoms.Past historynDenied history of tuberculosis or viral hepatitis, diabetes mellitus, hypertension, coronary heart disease, etc. nDenied history of trauma, surgery, blood transfusion,etc.nDenied food or drug allergy.System reviewnWe have not found o
6、ther symptoms except edema and foamed urine in review of systems.Personal HistorynHis personal history and family history are all not special.Physical examinationnT 36.5 HR 78 bpm RR 18/min BP 136/92mmHgnGood general state of health, skin color is normal,no cyanosis,no face edema,no tonsillar enlarg
7、ement.No abnormal breath sound was heard. No rales.Cardiac rhythm was regular,no pathological murmurs. The abdomen is flat and soft.There was not tenderness ,rebound tenderness and percussion pain on abdomen or renal region. Symmetric concave edema of both lower limbs.LaboratoriesNormalnBlood-RT, St
8、ool-RTnC3,C4,Alt, TBil,DBil, Glu,BUN, PT,INR,UBJP, AFP,CEAnHBsAg,HCV,HIVnTSH,FT3,FT4nRF,ASOn2-MGnANCA,ANA,dsDNA,Sm,SSA,SSBNormalnB-US of kidneys and heart were normal.AbnormalnAlb 21.0g/L,Cre 45.0umol/L,TG 1.84mmol/L,CHO 8.07mmol/L,HDL-C 1.62mmol/L,LDL-C 5.59mmol/L,ESR 25mm/h,D-D 1.12ug/mlnIgG 3.43,
9、IgM 0.33,IgA (normal)nU-pro(24h):3.01g/24h,Ccr 162ml/minnUrine:PRO +,RBC 33/uL,WBC 27.2/uL,NAG 46.4U/LDiagnosis and TreatmentnDiagnosis:Nephrotic SyndromenPresent treatments: Furosemide 20mg BID Valsartan 80mg QD Metoprolol 12.5mg BID Rosuvastatin 10mg QD Calcium Carbonate and Vitamin D3 600mg QD Prednisone 60mg QD Rabeprazole 20mg QDThank You!
