实践技能考试病案资料腰痛（Practical skills examination medical record data low back pain）.docVIP

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实践技能考试病案资料腰痛（Practical skills examination medical record data low back pain）.doc

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实践技能考试病案资料腰痛（Practical skills examination medical record data low back pain）

实践技能考试病案资料腰痛（Practical skills examination medical record data low back pain） Practical skills examination medical record data: low back pain Author: release time: 2008-05-25 source: Network The 05 question is dry: First station: medical record writing (60 minutes) Yue * *, male, 46 years old, civil servant, October 20, 2002 first visit. Repeated low back pain, lumbar soreness for 2 years, hi according to hi rub, in case of increased labor, urine foam more, due to busy work, did not pay attention to. In the past 2 weeks, the pain of lumbar pain is obvious, and the gas is weak, the legs and knees are weak, the hands and feet are not warm, and the urine is clear. Physical examination: T:36.8 degrees, R:18 / min, P:76 / min, BP:155/95 mmHg. God was flat, pallor, pale tongue, indented, thin white fur, thready pulse, no other positive signs. Laboratory examination: routine urine protein in red blood cells + +, ++/Hp, particle tube type 2-3/Lp. blood routine test showed: red blood cells 3.55 * 1012/L, hemoglobin 115g/l. blood urea nitrogen 6.8mmol/l creatinine, blood 100umol/l, blood uric acid 416umol/l, blood glucose (fasting) 5.6mmol/l, serum albumin 38g/l, immunoglobulin 28g/l.B ultra shows: normal renal size. The structure is fuzzy. Reference answer: Main words: repeated low back pain, lumbar acid, 2 years with bubble urine, aggravating 2 weeks On the basis of differentiation of diseases: because of the tired too, and the disease for a long time, and the loss of kidney essence, to moisten channels and the incidence of low back pain. The waist for the kidneys, kidney and bone marrow, kidney essence deficiency, lumbar spinal dystrophy, the numbness, pain, joy, hi rub, is seen as deficiency syndrome. Labor is the consumption of Qi, so it is more difficult to encounter labor. Kidney essence deficiency, Gushe company lost the nocturia, subtle is not solid and discharged, so the foam in urine. Yang deficiency can not warm limbs, so the hands and feet are not warm. The comple