实践技能考试病案资料腰痛（Practical skill test case data waist pain）.doc

实践技能考试病案资料腰痛（Practical skill test case data waist pain） Practical skill test case data: waist pain Author: publish time: 2008-05-25 source: network 05 dry: First stop: illness writing (60 minutes) Yue x, male, 46 years old, civil servant, on October 20, 2002. Repeated lumbar pain for two years, happy to knead, the treatment of fatigue, the urine foam more, because the work is busy, did not pay attention. In the last two weeks, my waist is sore and my legs are weak, my legs are weak and my limbs are not warm. Physical examination: T: 36.8 ℃, R: 18 times/min, P: 76 times/min, BP: 155/95 mmHg. God qing qi ping, complexion is white white, pale tongue fat, while there are teeth marks, moss thin white, pulse heavy fine, did not see other positive signs. Laboratory examination, routine urine: protein + +, RBC + + / Hp, particle type tube 2-3 / Lp. Blood routine: RBC 3.55 x 1012 / L, 115 g/l. hemoglobin, blood urea nitrogen tendency for 6.8 / L, 100 umol/L, serum creatinine and blood uric acid 416 umol/L, blood sugar (hollow) tendency for 5.6 / L, 38 g/L, plasma albumin globulin 28 g/l.B super: double kidney size to the normal range, the structure is fuzzy. Reference: Main statement: repeated lumbar pain of 2 years with foam urine, aggravated 2 weeks Differentiation of syndrome differentiation basis: because fatigue is too much, the illness is long, even kidney fine loss, do not have the waist ache that does not depend on the muscle. Lumbar is the kidney, the kidney master bone marrow, the kidney essence is deficient, the lumbar ridge is lost, so the acid is soft and weak, the pain of the pain, like to knead, is for the virtual certificate. Labor is more expensive, so it is worse. Kidney secretion, kidney deficiency and solid perturbation, therefore night urine increase, subtle and unsolid, so see foam urine. Yang deficiency cannot warm up the four limbs, so the foot is not warm. The complexion is white and white, the tongue is light and fat, the side has the tooth impressi