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一、病历摘要患者黄某,男,46岁,1984年6月7日入院.住院号:78357。患者于1984年1月因上呼吸道感染后出现颜面、下肢浮肿,以及尿少,尿黄,头痛,头晕,耳鸣,疲乏,恶心,呕吐,食欲减退等症状。但无膀胱刺激征及血尿。血压21.3~22.7/12~13.3kpa(160~170/90~100mmHg)。某县中医院诊为肾炎。经西药对症处理和服用健脾益气化湿中药均无效。近日来,因病情加重,每日尿量不足500ml,且自觉口苦、口臭,而转送我院。
First, the medical record summary patient Hwang, male, 46 years old, admitted to hospital on June 7, 1984. Hospital number: 78357. In January 1984, the patient developed facial, lower extremity edema, and oliguria, urine yellow, headache, dizziness, tinnitus, fatigue, nausea, vomiting, loss of appetite and other symptoms due to upper respiratory tract infection. But no bladder irritation and hematuria. The blood pressure was 21.3 to 22.7/12 to 13.3 kpa (160 to 170/90 to 100 mmHg). A county hospital was diagnosed with nephritis. Symptomatic treatment by Western medicine and taking spleen Qi and dampness of Chinese medicine are invalid. In recent days, due to aggravated condition, the daily urine volume is less than 500ml, and the consciously bitter taste and bad breath are transferred to our hospital.