國泰馬偕聯合病例討論會

Ｒ郭馨仁Ｖｓ吳志仁

Basic datas

• Name: 蔡ｘ峯• Age: 61 y/o • Sex: female• Chart no: 40149426• Date of admission: 97-11-14• Date of renal biopsy: 97-11-12 ( 亞東 ) • Underline disease: hyperlipidemia, DM, H

TN, VHD, hyperlipidemia

Chief complaint

• mild lower limbs pitting edema, right ankle pain with skin rash for 10 days

Present illness

• DM for 10 years with regular treatment • The bilateral lower leg pitting edema with j

oint tenderness over right ankle for 10 days

• Visited the 亞東 DERMA ward and transferred to AIR OPD (97-10-29) uveitis, arthralgiaR/O vasculitis medication: chlorzoxazone, salazopyrin, sulindac Some lower leg skin rash after taking 2 doses of the medications

• Admitted in 亞東 hospital

Present illness

• There were no malar rash, no haemoptysis , no neck mass, no neck stiffness, no dyspnea, no chest pain, no ecchymosis or fever condition, no tarry stool condition.

• There were no nausea, vomiting, no decreased urine output condition,

• Bilateral pleural effusionCT scan: iniflammation, transadate pleural effusion

• Impaired renal function renal Bx • s/p solumetrol 40 mg v Q8h due to the vasculitis conditio

n was considered• Admitted in our AIR ward after discharge from the 亞東

hospital

Past and personal history

• No smoking, no drinking, no drug abuse, or Chinese herb using history

• Allergy; denied• Family history: denied• Medication history: Euglucon 2# BID, avandia 1# QD, metformine 1#

BID, glucobay 1# TI, concor ½ # QD, bokey 1# QD,

Physical examination

• TPR: BT: 36, PR: 80, RR: 16, BP: 150/80 HEENT: mild pale conjunctiva, no icteric sclera,

no JVE• Chest: symmetric expansion, clear BS, basal ral

es• HEENT: RHB, without murmur• Abdomen: soft, hypoative BS, no localized tende

rness, no rebounding pain, no palpable liver or spleen, no knocking pain

• Extremity: mild lower leg pitting edema with some skin rash

Lab data: urine routine

PH SG WBC RBC protein glucose

97/11/

9 ( 亞東）

5.5 + 3-5 3+ -+

97/11/14

6.0 1.019 18 86 3+ --

97-11-17: urine protein/ creat: 398/30.7 = 13

Lab data Bun/creat N/K glucos Alb Chol TG Uric

acid

97/11/13 66/2.86 2.8

97/11/14 58/3.2 135/4.1 401

97/11/15 60/3.2 142/4 65 150 184

97/11/19 72/4.1 140/3.1

Lab data : 97/11

Ig G 1150 (75-1560) HCV Ab negative

IgA 381 (82-453) HBSAg negative

IgM 57 (46-304) ANCA c/p negative

IgE xx (10-180) C3 124 (79-152)

ANA negative C4 24 (16-38)

Anti-DS-DNA

negative Anti-SM negative

Anti-SSA negative Anti-RNP negative

Anti-SSB negative Anti-mitochontrial

negative

HLA-B 27 : negative （但在亞東醫院 positive ）

Lab data

WBC Hb PT-INR APTT

97/11/14 13.9 9.5 0.95 21.4

97/11/15 23.4 9.2

Stool OB : negative Cryoglobulin: negativeRheumatoid factor: negativeLupus anticoagulant: negativeAnti-cardiolipin: negative

Kidney ultrasound: normalCXR

normal kidney size