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國泰馬偕聯合病例討論會

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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  1. 國泰馬偕聯合病例討論會 Ｒ郭馨仁 Ｖｓ吳志仁

  2. 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

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

  4. 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

  5. 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

  6. 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,

  7. 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

  8. Lab data: urine routine 97-11-17: urine protein/ creat: 398/30.7 = 13

  9. Lab data

  10. Lab data : 97/11 HLA-B 27 : negative （但在亞東醫院 positive）

  11. Lab data Stool OB : negative Cryoglobulin: negative Rheumatoid factor: negative Lupus anticoagulant: negative Anti-cardiolipin: negative

  12. Kidney ultrasound: normalCXR normal kidney size

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