Detailed Treatment Process
Male, 18 years old Department: Orthopedics Outpatient Clinic Examination time: 4 years ago, June 12 Examination items: Anteroposterior view of sacroiliac joints, anteroposterior and lateral views of 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 without obvious abnormalities, and the vertebral appendages showed no changes. No obvious narrowing of the intervertebral spaces was seen. No obvious abnormal changes in the paravertebral soft tissues. The bones constituting 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 showed no obvious abnormalities, and there was no abnormal swelling in the surrounding soft tissue shadows. A translucent band shadow was visible in the center of the first sacral vertebra, with non-union of the bilateral laminae. Clinical diagnosis: Low back pain; lumbar and back myofascial inflammation ********* Laboratory test items: 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, June 12
Routine 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 Ketone bodies - (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 Turbid 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 Test 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 (131-172g/L) Hematocrit 50.9 (38.0-50.8%) Mean corpuscular volume 90.2 (83.9-99.1fL) Mean corpuscular hemoglobin 29.8 (27.8-33.8pg) Mean corpuscular hemoglobin concentration 330 (320-360g/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 (9.3-18.1fL) Mean platelet volume 11.7 (7.4-12.5fL) High-sensitivity C-reactive protein 0.41 (0.00-8.00mg/L)
Routine 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) Ketone bodies - (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 Turbid 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 Phase Report December 22 Clinical diagnosis: General medical examination 1. Total red blood cells 1013 (10,000/ml) 2. Dysmorphic red blood cells 283.64 (10,000/ml) 3. Dysmorphic red blood cell ratio 28 4. Red blood cell morphology Dysmorphic red blood cells were mainly small red blood cells, with visible burr red blood cells, ghost red blood cells, and shrunken red blood cells
Routine 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) Ketone bodies - (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 turbid 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 Phase Report December 28 Clinical diagnosis: General medical examination 1. Total red blood cells 310 (10,000/ml) 2. Dysmorphic red blood cells 186 (10,000/ml) 3. Dysmorphic red blood cell ratio 60 (%) 4. Red blood cell morphology Abnormal cells were mainly budding red blood cells
Outpatient Medical Record Visit date: December 30 Patient's chief complaint: Dark urine for 1 hour Present history: 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 ratio 60%; red blood cell morphology abnormal cells mainly budding red blood cells; December 30 Left renal vein "nutcracker" (color ultrasound): No definite "nutcracker" sign in the left renal vein. December 22 Bilateral kidneys + ureters + bladder (color ultrasound): No obvious abnormalities in bilateral kidneys, ureters, or bladder. December 21 Creatinine 81 μmol/L; glomerular filtration rate (EPI-cr) 120.7 ml/min; December 30 dysmorphic red blood cell ratio 51.72%; Suspected history of ankylosing spondylitis. No history of hepatitis B. Physical examination: Clear consciousness, normal mental status. 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 it.
Routine 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) Ketone bodies - (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 Phase Report December 30 Clinical diagnosis: Hematuria 1. Total red blood cells 58 (10,000/ml) 2. Dysmorphic red blood cells 30 (10,000/ml) 3. Dysmorphic red blood cell ratio 51.72% 4. Red blood cell morphology Red blood cells varied in shape, mainly small red blood cells and ring-shaped red blood cells
The doctor recommended kidney biopsy The family came to consult the author. The author inquired about the specific situation, and the family stated that on the day the urine turned dark, the whole family went hiking in the mountains around the urban area. The mountain peak was several hundred meters high, and the patient reached the summit. That evening after returning home, the dark urine occurred. A few days later, the family sent a message saying that CT examination revealed kidney stones.