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1病历摘要男,43岁。因右肾结石于1周前在外院行体外冲击波碎石术,往后自觉常感腰部不适,2 d前出现肉眼血尿,否认有外伤史。入院体检:T 36.4℃,P 112次/min,BP 105/60 mm Hg。神志清楚,查体合作,右肾稍隆起,轻压痛。B超检查提示:(1)右肾周积液(血肿可能);(2)右肾结石。上腹部CT见右肾周积液(血肿可能),包膜完整。血常规:Hb 105 g/L,HCT0·459。尿常规:RBC(+++),WBC(++)。
1 medical record male, 43 years old. Because of the right kidney stones in a hospital a week ago before extracorporeal shock wave lithotripsy, the latter often feel lumbar discomfort, 2 days before the gross hematuria, denied a history of trauma. Admission physical examination: T 36.4 ℃, P 112 times / min, BP 105/60 mm Hg. Consciousness, physical examination, the right kidney slightly elevated, soft tenderness. B-ultrasound tips: (1) right kidney fluid (hematoma may); (2) the right kidney stones. Right upper quadrant CT see the right kidney fluid (hematoma may), complete capsule. Blood: Hb 105 g / L, HCT0 · 459. Urine routine: RBC (+++), WBC (++).