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9、inary system: No decreased libido; No vaginal dryness or vaginal bleeding; History of STD denied; No urinary frequency. No precipitant urination or dysuria. No hematuria or proteinuria.Neuropsychiatric system: No convulsion or anesthesia. No headaches. No abnormal orientation. No deterioration of me
10、mory or intelligence.Locomotor system: No arthralgia, no muscular atrophies or dystrophies.Personal History:Born and grown up in Kunshan. Patient denied history of tobacco or alcohol use.Marital and Childbearing history: Married. 0-0-1-0; She had a curettage because of inevitable abortion in 2010Fam
11、ily history: No family history of DM or stroke. No family history of nervous or mental diseases.Physical ExaminationT: 37.1 P: 80/min R: 19/min BP: 120/70mmHgGeneral appearance: Patient is a 3() years old female who appears pleasant, in no apperant distress, given her age, well developed and well no
12、urished. Oriented to person, place and time.Lymph nodes: Not enlarged.Skin: No jaundice or rashes. No cyanosis and bruises. No edema.Head: Skull and scalp normal. No tenderness. No loss of hair.Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No
13、 jaundice. Pupils size and shape is normal. Corneal is clear. No exophthalmos.Ears: Auditory acuity is excellent. No ear purulent discharge.Nose: Shape is normal. No obstruction. No deviation of nasal septum.Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tons
14、ils not enlarged.Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.Lung:Inspection: Respiration regular. Degree of expansion is sym
15、metry.Plapation: Tactile fremitus symmetrical.Percussion: extensive resonance to percussion.Ausculation: Clear to ausculation with no rubs noted.Heart:Inspection: No abnormal pulsation or retraction.Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicu
16、lar line.Percussion: The border of cardiac is not enlarged.Ausculation: The heart sounds were of good quality and the rhythm was regular. Heart rate: 96/min. No bruits.Right(cm)Rib interspaceLeft(cm)The left mid-clavicular line is 9 cm away from front midsternal line. Radial pulse is normal.2II23III
17、44IV6V8Abdomen:Inspection: Universial abdominal bulge. Dilated veins observed.Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy9s sign is negative. For details see obstetric examination.Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space
18、.Ausculation: Bowl sound clear. 4/min.Spine and extremities: Severe edema in both lower extremities. No clubbed finger. No disorder of the movement of axial and appendicular bones.Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negat
19、ive.Obstetric examinationPatient appears pleasant, given her age, well developed and well nourished. No jaundice. No enlarged lymph nodes.Fetus: Abdominal girth:91cm; height of fundus: 26cm; fetal heart rate: 150/min; FM: active.Anorectal examination: fetal membrane: not ruptured.Flexion of knee: ac
20、tive.Laboratory and special examinationDec. 6th, Blood Rt: Hb: 121g/L; PLT 136X10e9Urine Rt: uric protein(+); occlude blood: (+)Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL: 51mm; HL: 49mm. fetal presentation: head; Position of placenta: right wall of uterus. Thickness of placenta
21、: 23mm. Degree of placental maturity: II; fetal heartbeat and fetal movement seen; amniotic fluid: 64mm. There is no hematocoelia or ascites. The lower edge of placenta is 23mm from the cervix.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec. 10
22、th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LFeatures of the case:1. Female, 38years old, G2P0, GW: 30+5weeks.2. This patient presents hypertension for 3 months, and systemic edema for 2 weeks.3. PE: BP: 180/120mmHg. Obstetric exam: Fetus: Abdominal girth: 93cm; height of fundus
23、: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: 卞；fetal heart rate: 148/min; FM: active.Flexion of knee: active.4. Laboratory and special exam:Aug. 7th, Blood Rt: Hb: 122g/L; PUT 129X 10e9; WBC 7. 13X109/L;N% 77. 5% HUrine Rt: uric protein(-); LEU 500/ul HAug.8
24、th,ALT: 11U/L;AST: 18U/LDiagnosis and differential diagnosis:Diagnosis: G2P0, GW: 31 weeks, premature signs, SLEDifferential diagnosis:1. Chronic hypertension due to renal disease. This includes chronic hypertension due to interstitial nephritis, chronic glomerulonephritis, SLE, diabetic glomerulosc
25、lerosis, and so on. In these occasions, the patient would also possibly present hypertension, proteinuria and edema, but her proteinuria was found recently and she didnt have any symptoms associated with renal diseases previously. In addition, her serum creatinine is in the normal scale (Scr: 86umol
26、/L), which contradicts the hypothesis that she has a renal disease. So the diagnosis of chronic hypertension due to renal disease is not considered at present.Further investigations and treatments:2. Close observation and monitoring, plus quick evaluation: daily monitoring of protein in urine; Regul
27、ar liver and kidney function testing; Ultrasound of the abdomen; Fetus heartbeat monitor; Conduct PT, APTT, FDP, 3P test to evaluate the coagulant function.3. Rests: Lie in bed on left side.4. Use prednisone , hydroxychloroquine sulfate , aspirin to control the development of SLE5. Use ritodrine to prevent miscarriageClinic diagnosis:G2P0, GW: 31 weeks, premature signs, SLESigniture: