100个医学病例10
CASE10
BACK PAIN
后背痛
History
A 27-year-old woman is admitted to the emergency department complaining of pain across her back. She became unwell 2 days previously when she started to develop a fever and an ache in her back. The pain has become progressively more severe. She has vomited twice in the past 6 h. She has had no previous significant medical history, apart from an uncomplicated episode of cystitis 3 months ago.
患者，女，27岁，因"后背痛"于急诊室就诊。2天前患者出现后背痛，伴发热。疼痛逐渐加重。6小时来，患者呕吐两次。3月前有"不完全性发作性膀胱炎"，否认其他特殊医学史。
Examination
She looks unwell and is flushed. Her temperature is 39.5°C. Her pulse is 120 beats/min and blood pressure 104/68 mmHg. Examination of the cardiovascular and respiratory systems is unremarkable. Her abdomen is generally tender, but most markedly in both loins. Bowel sounds are normal.
患者（急性）病容，面色潮红。测体温39.5℃，脉率120次/分，血压104/68mmHg。心血管及呼吸系统未见明显异常。全腹部压痛阳性，两侧腰部显著。肠鸣音正常。
这里虽然没有写是急性还是慢性病容，只写着looks unwell（看起来不好，染病，抱恙），但根据患者上文可以分析得到，患者起病时间短，数天，所以为急性发作，这里可以翻译为医学术语急性病容。
INVESTIGATIONS
实验室及影像学检查
| 项目 | 结果 | 参考范围 |
|---|---|---|
| Haemoglobin | 15.3 g/dL | 11.7–15.7 g/dL |
| White cell count | 25.2 � 109/L | 3.5–11.0 � 109/L |
| Platelets | 406 � 109/L | 150–440 � 109/L |
| Sodium | 134 mmol/L | 135–145 mmol/L |
| Potassium | 4.1 mmol/L | 3.5–5.0 mmol/L |
| Urea | 14.2 mmol/L | 2.5–6.7 mmol/L |
| Creatinine | 106 umol/L | 70–120 umol/L |
| Albumin | 44 g/L | 35–50 g/L |
| C-reactive protein (CRP) | 316 mg/L | ＜5 mg/L |
Urinalysis: ++ protein; +++ blood; ++nitrites
尿液分析：蛋白 ++；潜血 +++；亚硝酸盐++
Urine microscopy: ＞ 50 red cells; ＞ 50 white cells
尿显微镜检：红细胞 ＞50；白细胞 ＞50
Abdominal X-ray: normal
腹部平片（X线片）：正常
This woman has the symptoms and signs of acute pyelonephritis. Acute pyelonephritis is much more common in women than men, and occurs due to ascent of bacteria up the urinary tract. Pregnancy, diabetes mellitus, immunosuppression and structurally abnormal urinary tracts increase the likelihood of ascending infection.
该女性患者有急性肾盂肾炎症状（symptom）和体征（sign）。急性肾盂肾炎好发于女性，发病多由于泌尿道细菌增多。怀孕，糖尿病，免疫表达及泌尿道结构异常增加了感染的可能性。
Differential diagnosis
鉴别诊断
Pyelonephritis causes loin pain which can be unilateral or bilateral. The differential diagnoses of loin pain include obstructive uropathy, renal infarction, renal cell carcinoma, renal papillary necrosis, renal calculi, glomerulonephritis, polycystic kidney disease, medullary sponge kidney and loin-pain haematuria syndrome.
肾盂肾炎可导致单侧或双侧腰部疼痛。腰痛的鉴别诊断包括梗阻性尿路疾病，肾梗死，肾细胞瘤，肾乳头坏死，肾结石（calculi表示结石，同时还有微积分的意思），肾小球肾炎，多囊肾，髓质海绵肾及腰痛血尿综合征。
Fever may be as high as 40°C with associated systemic symptoms of anorexia, nausea and vomiting. Some patients may have preceding symptoms of cystitis (dysuria, urinary frequency, urgency and haematuria), but these lower urinary tract symptoms do not always occur in patients with acute pyelonephritis. Many patients will give a history of cystitis within the previous 6 months. Elderly patients with pyelonephritis may present with nonspecific symptoms and confusion. Pyelonephritis may also mimic other conditions such as acute appendicitis, acute cholecystitis, acute pancreatitis and lower lobe pneumonia. There is usually marked tenderness over the kidneys both posteriorly and anteriorly. Severe untreated infection may lead on to septic shock.
发热最高可达40℃，可伴有全身症状如厌食，恶心呕吐。一些患者会有膀胱炎的先驱症状（无尿，尿频，尿急，血尿），但不是急性肾盂肾炎患者都会有上述下泌尿道症状。许多患者发病前6个月有膀胱炎病史。老年肾盂肾炎患者可有不典型症状和表现。肾盂肾炎可有其他疾病的表现如急性阑尾炎，急性胆囊炎，急性胰腺炎及下叶肺炎。肾前区及肾后区均可触及压痛。严重感染未治疗会导致感染性休克。
The raised white cell count and CRP are consistent with an acute bacterial infection.Microscopic haematuria, proteinuria and leucocytes in the urine occur because of inflammation in the urinary tract. The presence of bacteria in the urine is confirmed by the reduction of nitrates to nitrites.
白细胞计数及超敏c反应蛋白（CRP）升高，提示急性细菌性感染。显微镜检血尿，蛋白尿，尿白细胞是由于泌尿道感染。（尿）亚硝酸盐证实了尿液中存在有细菌。
This woman should be admitted. Blood and urine cultures should be taken, and she should be commenced on intravenous fluids and antibiotics, until the organism is identified, and then an oral antibiotic to which the organism is sensitive can be used. Initial therapy could be with gentamicin and ampicillin, or ciprofloxacin. She should have a renal ultrasound scan to exclude any evidence of obstruction. In patients with obstructive uropathy,infection may lead to a pyonephrosis with severe loin pain, fever, septic shock and renal failure. If there is evidence of a hydronephrosis in the context of urinary sepsis, a nephrostomy should be inserted urgently to prevent these complications.
该女性患者需进一步确诊。可完善血液及尿液培养监测，同时，她可以静脉使用药物及抗生素，直到（培养）确定微生物，可口服对该微生物敏感的抗生素。初始治疗可使用庆大霉素，氨苄西林或环丙沙星。该患者应完善肾脏彩超排除梗阻。在尿路梗阻患者中，感染会导致肾积脓，伴有严重腰部疼痛，发热，感染性休克及肾衰竭。如有继发于尿脓毒血症的肾积水表现，应及时行肾造瘘术预防并发症。
Patients with an uncomplicated renal infection should be treated with a 2-week course of antibiotics, and then have a repeat culture 10–14 days after treatment has finished to confirm eradication of infection. In patients with infection complicated by stones, or renal scarring, a 6-week course of treatment should be given.
单纯（无并发症）的肾感染患者应使用抗生素治疗2周后10-14天复查培养（尿/血），确保感染完全吸收（eradicate表示根治的意思，这里和感染搭配可使用吸收等词语）。感染并发有结石或肾瘢痕（形成），抗生素需使用6周。
