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R4 張祐銘 VS 彭聖曾醫師
馬偕國泰病理討論會
General data• Chart Number ： 0803472902• Name ：涂 X 治• Age ： 68• Gender: male• Marriage Status: married• Source of information: the patient himself
and his son, old medical history, reliable
Past historyDM: deniedHypertension: 2 years with irregular control
at 竹東榮民醫院 .BPH for 2 years with irregular control at 竹東
榮民醫院Operation history:
HIVD s/p op at 署立台北醫院 in 1999.
Chief complaintprogressive general malaise for about 3-4
months
Present illnessThis 69 year-old man had a history of HTN and
BPH for 2 years.His medications included: Harnalidge 1# hs, Tanatril 1#qd from 竹東榮民
H 97/11/17 Lasix 40mg 1#bid, Carvedilol 6.25mg
1# bid 97/11/19 Lasix 40mg, Trichlormethiazide 2mg
1# qd 97/11/26 Lasix 40mg, Nifedipine SR 30mg
1#bid, Bisoprolol 5mg 1#qd
Since 97/8, he got edematous status and soreness over bilateral legs. He became weakness so that he could not play tennis any more. His hypertension exacerbated.
He took traditional Chinese herb once in 97/9. Due to soreness, NSAID was also prescribed from 竹東榮民 H.
In 97/10, there was exertional dyspnea. Palpitation, dizziness and cold sweating also occurred from time to time.
No tarry stool, nausea, vomiting, poor appetite, body weight loss, chest tightness, chest pain, flank pain, tea-color urine or decreased urine amount was noted.
He went to 新竹國泰 OPD on 97/11/17 and renal failure (BUN/Cr : 37 / 2.87) was found.
His clinical symptoms (aching, weakness) did not improve and his renal function kept on deterioration.
Under the impression of acute renal failure with unknown origin,he was transferred to 台北國泰 for renal biopsy on 97/12/23.
Physical examinationBody weight: 75.5 kg Body height: 175 cmVital sign: BP 160/90 mmHg, BT 36.5 ℃, HR
60 BPM, RR 18 /min General appearance: chronic ill-lookingConsciousness: clearHEENT: conjunctiva: mild pale, sclera:
anicteric Neck: supple, JVE (-/-), LAP (-/-)
Chest: accessory muscle respiration (-), rales (-), rhonchi (-), wheezing (-)
Heart: RHB, S3 (-), S4 (-), murmur (-) Abdomen: distension (-), tenderness (-), muscles
guarding (-), rebounding pain (-), palpable mass (-), hepatosplenomegaly (-), shifting dullness (-), tympanic (-), knocking pain (-), normal active bowel sound
Flank: knocking pain L/R (-/-), pressure sore (-)EXT: freely movable, pitting edema (+/+)Skin: rash (-), petechiae (-)
date 97/8
11/17
11/26
11/29
12/18
12/23
98/1/5
1/12
1/13
1/14
BUN 20 37 73 61 59 74 76 106
102
101
Cr 1.1 2.87 3.04 2.91 3.76 4.2 4.98 5.5 5.7 5.6
Uric acid 11.4 11.0
Total protein
6.0 5.6
albumin 3.3 3.1 2.9
Cholesterol
162 139
TG 207 120
Ca 8.2 8.7 8.7 8.7 8.6
P 3.9 5.1 5.1 5.5 5.2
Na 140 139 139 131 138
140
K 3.1 3.7 3.9 5.2 4.1 3.8
GOT 20 19 23 24
GPT 12 17 17 11 19
Bilirubin T/D
0.8/0.1
0.3/0.1
11/17
11/26
12/18
12/23
12/24
Hb 8.8 10.1 9.3 8.8
Hct 26.3 30.0 28.0 26.3
MCV 87 88 88 88
WBC 8.51 10.7 10.25
9.3
Platelet
106 141 171 146
urine
protein
56.8
Urine Urine
Cr 36.8
RBC 0-2 0-3
WBC 2-4 0-5
Protein
(-) 30
SpGr 1.007
1.014
PH 5 5.5
Glucose
- -
Cast - -
11/26
11/28 12/23
Haptoglobin < 10 < 10
Reticulocyte 1.75 (0.5- 1.5)
2.66
Fe 34
TIBC 205
Ferritin 792
AC sugar 88
LDH 282
Stool O.B. (-)
12/23
RA: < 20 (0-30)
ANA: 1:80, speckle
Anti-cardiolipin IgM: 3.8
ASLO: 27.4 (0-116)
Coomb’s test (D): ±
Anti-cardiolipin IgG: 4.4
IgA: 197 (160-314)
Coomb’s test (I): -
Anti-dsDNA: 1.18 (-)
IgM: 89 (79-195)
C-ANCA: - Anti-RNP Ab: 1.27 (-)
IgG: 1430 (940-1398)
P-ANCA: - Anti-SM Ab: 0.31 (-)
C3: 84 (86-128)
C4: 22.4(16-32) HBsAg(-), Anti-HCV(-)
Renal biopsy was done on 97/12/23
date 97/8
11/17
11/26
11/29
12/18
12/23
98/1/5
1/12
1/13
1/14
BUN 20 37 73 61 59 74 76 106
102
101
Cr 1.1 2.87
3.04 2.91
3.76
4.2 4.98 5.5 5.7 5.6
Uric acid 11.4 11.0
Total protein
6.0 5.6
albumin 3.3 3.1 2.9
Cholesterol
162 139
TG 207 120
Ca 8.2 8.7 8.7 8.7 8.6
P 3.9 5.1 5.1 5.5 5.2
Na 140 139 139 131 138
140
K 3.1 3.7 3.9 5.2 4.1 3.8
GOT 20 19 23 24
GPT 12 17 17 11 19
Bilirubin T/D
0.8/0.1
0.3/0.1
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