Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may be blank or contain nonspecific complaints depending on the type and severity of hyperoxaluria.
Kidney stones (most common symptom in primary hyperoxaluria)
Flank pain, hematuria (with kidney stones)
Bone pain, fractures (in some types of hyperoxaluria)
Fatigue, weakness
Joint pain (less common)
Urinary tract infections (may be recurrent)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset, duration, and severity of symptoms
Recent hospitalizations or emergency department visits (e.g., for kidney stones)
Frequency of urination (may be increased)
Presence of blood in urine (hematuria)
Past episodes of kidney stones
Family history of kidney stones (important clue)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hyperoxaluria (inflammatory bowel disease, short bowel syndrome) – relevant for secondary hyperoxaluria
History of kidney stones or other urologic issues
Prior surgeries or procedures (e.g., kidney stone removal)
Medications (current and recent) – including vitamin C supplements, some medications can increase oxalate production
家族史 (jiā zú shǐ) Family History:
History of kidney stones in first-degree relatives (suggestive of primary hyperoxaluria)
Family history of other inherited disorders (important for some types of primary hyperoxaluria)
社会史 (shè huì shǐ) Social History:
Diet (high oxalate intake can worsen hyperoxaluria)
Fluid intake (inadequate hydration can increase risk of kidney stones)
Bowel habits (diarrhea can contribute to secondary hyperoxaluria)
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure, heart rate, temperature) – may be abnormal in advanced disease
General appearance (signs of chronic illness)
Abdominal exam (palpation for kidney tenderness)
Joint exam (may reveal tenderness or swelling)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Urinalysis:
Microscopic examination for crystals (calcium oxalate crystals suggestive)
Urine oxalate level (confirms diagnosis)
Serum electrolytes (may show abnormalities with kidney dysfunction)
Kidney function tests (creatinine, BUN) – to assess kidney function
Genetic testing (may be considered to identify specific type of primary hyperoxaluria)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Abdominal X-ray or CT scan: may show kidney stones
Kidney ultrasound: may reveal kidney stones or damage
诊断 (zhěn duàn) Diagnosis:
Hyperoxaluria (primary or secondary)
Specific type of hyperoxaluria (if identified)
Presence of kidney stones or other complications (e.g., chronic kidney disease)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment depends on the type and severity of hyperoxaluria.
Dietary modifications (low oxalate diet)
Increased fluid intake
Medications:
Pyridoxine (vitamin B6) – may decrease oxalate production (primary hyperoxaluria type 1)
Citrate therapy – binds to oxalate in urine to prevent stone formation
Allopurinol (for some types)
Surgery (for kidney stones or severe complications)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the type of hyperoxaluria, severity, and adherence to treatment.
Early diagnosis and treatment are crucial to prevent kidney stones and other complications.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of dietary modifications (low oxalate diet)
Maintaining adequate hydration
Importance of medication adherence
Warning signs of worsening hyperoxaluria or kidney stones (increased pain, blood in urine)
Importance of regular follow-up to monitor kidney function and oxalate levels
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of hyperoxaluria