Detailed Treatment Process
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Male, 18 years old Department: Orthopedics Outpatient Clinic Examination time: 4 years ago on June 12 Examination items: Anteroposterior view of the sacroiliac joints, anteroposterior and lateral views of the lumbar spine Examination sites: Sacroiliac joints, lumbar spine Imaging findings: The lumbar spine showed normal physiological curvature. The morphology and density of the visible lumbar vertebral bodies were unremarkable, with no changes in the vertebral appendages. No obvious narrowing of the intervertebral spaces was seen. Paravertebral soft tissues showed no significant abnormalities. The bones forming the pelvic ring were normally aligned, with no obvious abnormalities in bone structure. The morphology and bone structure of the bilateral sacroiliac joints and hip joints were unremarkable, and there was no abnormal swelling in the surrounding soft tissues. A radiolucent band was visible in the center of the first sacral vertebra, with non-fusion of the bilateral laminae. Clinical diagnosis: Low back pain; lumbar and back myofascial inflammation ********* Laboratory tests: Department: Orthopedics Outpatient Clinic Clinical diagnosis: Low back pain; lumbar and back myofascial inflammation 1 HLA-B27CD3: Positive 2 Mean fluorescence intensity: 162.00 Examination time: 4 years ago on June 12
Urinalysis Report Clinical diagnosis: General medical examination December 21 1 Occult blood +++(200) (negative Ery/μl) 2 Leukocyte esterase +-(15) (negative leu/μl) 3 Protein ++(1.00) (negative g/L) 4 Bilirubin - (negative umol/L) 5 Urobilinogen normal (normal umol/L) 6 Ketones - (negative mmol/L) 7 Nitrite - (negative) 8 Glucose - (negative mmol/L) 9 pH 6.5 (4.5-8.0) 10 Specific gravity 1.001 (1.003-1.030) 11 Turbidity cloudy 12 Color red 13 Red blood cells 73041.3 (0-8 /μl) 14 White blood cells 145.6 (0-10 /μl) 15 Hyaline casts 0.0 (0-1 /μl) 16 Squamous epithelial cells 0.0 (0-2 /μl) 17 Non-squamous epithelial cells 0.0 (0-1 /μl) 18 Calcium oxalate crystals 0.0 (/μl) 19 Uric acid crystals 0.0 (/μl) 20 Magnesium ammonium phosphate crystals 0.0 (/μl) 21 Yeast 11171.1 (0-1 /μl) 22 Bacteria 0.0 (0-200 /μl) 23 Mucus threads 0.0 (/μl) ********* Renal Function Report December 21 Clinical diagnosis: General medical examination 1 Creatinine 81 (57-97) 2 Urea 5.58 (3.10-8.00) 3 Urea/creatinine 17.1 4 Uric acid 337 (208-428) 5 Glomerular filtration rate (EPI-cr) 120.7
Complete Blood Count Report December 21 Clinical diagnosis: General medical examination White blood cell count 9.56 (4.0-10.0 × 10⁹/L) Neutrophils (%) 66.5 (50.0-70.0%) Lymphocytes (%) 26.8 (20.0-40.0%) Monocytes (%) 5.0 (3.0-10.0%) Eosinophils (%) 1.4 (0.5-5.0%) Basophils (%) 0.3 (0.0-1.0%) Neutrophils 6.36 (2.0-7.0 × 10⁹/L) Lymphocytes 2.56 (0.8-4.0 × 10⁹/L) Monocytes 0.48 (0.12-1.00 × 10⁹/L) Eosinophils 0.13 (0.02-0.50 × 10⁹/L) Basophils 0.03 (0.00-0.10 × 10⁹/L) Red blood cell count 5.64 (4.09-5.74 × 10¹²/L) Hemoglobin 168 (131-172 g/L) Hematocrit 50.9 (38.0-50.8%) Mean corpuscular volume 90.2 (83.9-99.1 fL) Mean corpuscular hemoglobin 29.8 (27.8-33.8 pg) Mean corpuscular hemoglobin concentration 330 (320-360 g/L) Red cell distribution width 12.2 (11.5-14.5%) Platelet count 252 (83-303 × 10⁹/L) Plateletcrit 0.293 (0.108-0.282%) Platelet distribution width 16.4 (9.3-18.1 fL) Mean platelet volume 11.7 (7.4-12.5 fL) High-sensitivity C-reactive protein 0.41 (0.00-8.00 mg/L)
Urinalysis Report December 22 Clinical diagnosis: General medical examination Occult blood +++(200) (negative Ery/μl) Leukocyte esterase - (negative leu/μl) Protein +(0.30) (negative g/L) Bilirubin - (negative umol/L) Urobilinogen normal (normal umol/L) Ketones - (negative mmol/L) Nitrite - (negative) Glucose - (negative mmol/L) pH 6.0 (4.5-8.0) Specific gravity 1.016 (1.003-1.030) Turbidity cloudy Color red Red blood cells 10132.9 (0-8/μl) White blood cells 26.6 (0-10/μl) Hyaline casts 0.0 (0-1/μl) Squamous epithelial cells 0.0 (0-2/μl) Non-squamous epithelial cells 0.0 (0-1/μl) Calcium oxalate crystals 0.0 (/μl) Uric acid crystals 0.0 (/μl) Magnesium ammonium phosphate crystals 0.0 (/μl) Yeast 0.0 (0-1/μl) Bacteria 900.5 (0-200/μl) Mucus threads 8.8 (/μl)
Urinary Red Blood Cell Morphology Report December 22 Clinical diagnosis: General medical examination 1. Total red blood cells 1013 (×10⁴/ml) 2. Dysmorphic red blood cells 283.64 (×10⁴/ml) 3. Dysmorphic red blood cell percentage 28 4. Red blood cell morphology: Dysmorphic cells mainly small red blood cells, with visible burr cells, ghost cells, and shrunken red blood cells
Urinalysis Report December 28 Clinical diagnosis: Urinary tract infection Occult blood +++(200) (negative Ery/μl) Leukocyte esterase - (negative leu/μl) Protein +(0.30) (negative g/L) Bilirubin - (negative umol/L) Urobilinogen normal (normal umol/L) Ketones - (negative mmol/L) Nitrite - (negative) Glucose - (negative mmol/L) pH 5.0 (4.5-8.0) Specific gravity 1.015 (1.003-1.030) Turbidity slightly cloudy Color light yellow Red blood cells 3175.0 (0-8/μl) White blood cells 9.2 (0-10/μl) Hyaline casts 0.0 (0-1/μl) Squamous epithelial cells 0.3 (0-2/μl) Non-squamous epithelial cells 0.0 (0-1/μl) Calcium oxalate crystals 0.0 Uric acid crystals 0.0 Magnesium ammonium phosphate crystals 0.0 Yeast 0.0 (0-1/μl) Bacteria 416.5 (0-200/μl) Mucus threads 22.1
Urinary Red Blood Cell Morphology Report December 28 Clinical diagnosis: General medical examination 1. Total red blood cells 310 (×10⁴/ml) 2. Dysmorphic red blood cells 186 (×10⁴/ml) 3. Dysmorphic red blood cell percentage 60 (%) 4. Red blood cell morphology: Abnormal cells mainly budding red blood cells
Outpatient Medical Record Visit date: December 30 Chief complaint: Dark urine for 1 hour History of present illness: Dark urine for 1 hour, no urgency or pain on urination, no fever or low back pain. December 21: Occult blood +++(200) Ery/μl; leukocyte esterase +-(15) leu/μl; protein ++(1.00) g/L; red blood cells 73041.3/μl; white blood cells 145.6/μl; yeast 11171.1/μl. December 28: Occult blood +++(200) Ery/μl; protein +(0.30) g/L; specific gravity 1.015; red blood cells 3175.0/μl; dysmorphic red blood cell percentage 60%; red blood cell morphology mainly budding red blood cells. December 30: Left renal vein “nutcracker” (color Doppler ultrasound): No definite “nutcracker” sign in the left renal vein. December 22: Kidneys + ureters + bladder (color Doppler ultrasound): No obvious abnormalities in the kidneys, ureters, or bladder. December 21: Creatinine 81 μmol/L; glomerular filtration rate (EPI-cr) 120.7 ml/min; dysmorphic red blood cell percentage on December 30: 51.72%. Suspected history of ankylosing spondylitis. No history of hepatitis B. Physical examination: Alert, good spirits. Height 172 cm, weight 58 kg. Diagnosis: 1. Nephritic syndrome; 2. Urinary tract infection Treatment plan: Recommend completing etiological screening; kidney biopsy if necessary. The patient and family indicated they needed to consider this.
Urinalysis Report December 30 Clinical diagnosis: Hematuria Occult blood +++(200) (negative Ery/μl) Leukocyte esterase - (negative leu/μl) Protein - (negative g/L) Bilirubin - (negative umol/L) Urobilinogen normal (normal umol/L) Ketones - (negative mmol/L) Nitrite - (negative) Glucose - (negative mmol/L) pH 5.0 (4.5-8.0) Specific gravity 1.022 (1.003-1.030) Turbidity clear Color light yellow Red blood cells 628.0 (0-8/μl) White blood cells 2.5 (0-10/μl) Hyaline casts 0.0 (0-1/μl) Squamous epithelial cells 0.0 (0-2/μl) Non-squamous epithelial cells 0.0 (0-1/μl) Calcium oxalate crystals 0.0 Uric acid crystals 0.0 Magnesium ammonium phosphate crystals 0.0 Yeast 0.0 (0-1/μl) Bacteria 93.8 (0-200/μl) Mucus threads 18.5
Urinary Red Blood Cell Morphology Report December 30 Clinical diagnosis: Hematuria 1. Total red blood cells 58 (×10⁴/ml) 2. Dysmorphic red blood cells 30 (×10⁴/ml) 3. Dysmorphic red blood cell percentage 51.72% 4. Red blood cell morphology: Varied red blood cell shapes, mainly small red blood cells and ring-shaped red blood cells
The doctor recommended a kidney biopsy. The family came to consult the author. When asked for details, the family reported that on the day the urine turned dark, the whole family had gone hiking in the mountains near the city. The peak was several hundred meters high, and the patient had reached the summit. That evening, after returning home, the dark urine appeared. Several days later, the family reported that a CT scan had revealed kidney stones.