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國泰馬偕聯合病例討論會

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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, HTN, VHD, hyperlipidemia. Chief complaint.

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國泰馬偕聯合病例討論會

R郭馨仁

Vs吳志仁

basic datas
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, HTN, VHD, hyperlipidemia
chief complaint
Chief complaint
  • mild lower limbs pitting edema, right ankle pain with skin rash for 10 days
present illness
Present illness
  • DM for 10 years with regular treatment
  • The bilateral lower leg pitting edema with joint tenderness over right ankle for 10 days
  • Visited the 亞東 DERMA ward and transferred to AIR OPD (97-10-29) uveitis, arthralgiaR/O vasculitis medication: chlorzoxazone, salazopyrin, sulindacSome lower leg skin rash after taking 2 doses of the medications
  • Admitted in 亞東 hospital
present illness1
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 effusionCT scan: iniflammation, transadate pleural effusion
  • Impaired renal function renal Bx
  • s/p solumetrol 40 mg v Q8h due to the vasculitis condition was considered
  • Admitted in our AIR ward after discharge from the 亞東 hospital
past and personal history
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
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 rales
  • HEENT: RHB, without murmur
  • Abdomen: soft, hypoative BS, no localized tenderness, 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
Lab data: urine routine

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

lab data 97 11
Lab data : 97/11

HLA-B 27 : negative (但在亞東醫院 positive)

lab data1
Lab data

Stool OB : negative

Cryoglobulin: negative

Rheumatoid factor: negative

Lupus anticoagulant: negative

Anti-cardiolipin: negative

kidney ultrasound normal cxr
Kidney ultrasound: normalCXR

normal kidney size

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