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

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6114061

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

Lab data


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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