Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to infection-related glomerulonephritis. This may include:
Blood in the urine (hematuria) – may be gross (visible) or microscopic
Foamy urine (proteinuria)
Decreased urine output (oliguria) – may be absent in early stages
Malaise, fatigue, or weakness
Fever (if associated infection is present)
High blood pressure (may develop)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Severity of symptoms (e.g., gross hematuria, frequency of urination).
Recent history of infection (upper respiratory tract infection, skin infection, etc.).
Specify the type of infection if known.
Presence of any risk factors for infection-related glomerulonephritis (e.g., autoimmune disorders).
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions (e.g., diabetes, hypertension) that may worsen kidney function.
Prior history of kidney disease or urinary tract infections (UTIs).
Prior surgeries or procedures (especially involving the kidneys).
家族史 (jiā zú shǐ) Family History:
Family history of kidney disease (uncommon).
社会史 (shè huì shǐ) Social History:
Medications (prescription and over-the-counter) – certain medications can affect the kidneys.
Tobacco, alcohol, or illicit drug use (risk factors for kidney disease).
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show signs of volume overload if kidney function is severely impaired).
General examination: assess for signs of edema (fluid retention).
Cardiovascular examination: assess for high blood pressure and signs of heart failure (if present).
Abdominal examination: assess for kidney size or tenderness.
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Urinalysis:
Hematuria, proteinuria, and white blood cells (may indicate infection)
Urine culture: To identify and rule out a urinary tract infection (UTI) as the source.
Kidney function tests (electrolytes, creatinine, BUN):
Assess kidney function and potential for electrolyte imbalances.
Complete blood count (CBC): May show anemia if kidney function is severely impaired.
Anti-streptolysin O (ASO) titer or other serological tests:
May be helpful in identifying a recent streptococcal infection as a potential trigger.
Anti-glomerular basement membrane (anti-GBM) antibody test:
To rule out less common causes like Goodpasture’s syndrome.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Ultrasound of the kidneys: Assess kidney size, echogenicity, and rule out obstruction.
Kidney biopsy (considered definitive diagnosis but may not be routinely done):
Examines kidney tissue under a microscope to identify the specific type of glomerulonephritis.
诊断 (zhěn duàn) Diagnosis:
Infection-related glomerulonephritis (post-infectious glomerulonephritis).
Specify the suspected type based on clinical presentation and serological tests (e.g., post-streptococcal glomerulonephritis).
分期 (fēn qī) Staging (optional):
Some classification systems categorize infection-related glomerulonephritis based on severity.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment aims to address the underlying infection (if present), manage symptoms, and support kidney function.
Specific medications will depend on the severity of kidney function impairment and the presence of other medical conditions. May include:
Antibiotics (if a UTI is identified)
Antiplacental drugs (corticosteroids or other immunosuppressants) – to reduce inflammation in the glomeruli.
Diuretics (to remove excess fluid if present).
Blood pressure medications (to control hypertension and protect kidney function).
Dietary modifications (may be needed to manage protein intake or electrolyte imbalances).
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of glomerulonephritis and kidney function.
Most cases