1. R4 張祐銘 VS 彭聖曾醫師 馬偕國泰病理討論會

2. 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

3. Past history DM: denied Hypertension: 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.

4. Chief complaint progressive general malaise for about 3-4 months

5. Present illness This 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

6. 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.

7. 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.

8. 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.

9. Physical examination Body weight: 75.5 kg Body height: 175 cm Vital sign: BP 160/90 mmHg, BT 36.5 ℃, HR 60 BPM, RR 18 /min General appearance: chronic ill-looking Consciousness: clear HEENT: conjunctiva: mild pale, sclera: anicteric Neck: supple, JVE (-/-), LAP (-/-)

10. 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 (-)

11. date97/811/1711/2611/2912/1812/2398/1/51/121/131/14 BUN20377361597476106102101 Cr1.12.873.042.913.764.24.985.55.75.6 Uric acid11.411.0 Total protein 6.05.6 albumin3.33.12.9 Cholesterol162139 TG207120 Ca8.28.7 8.6 P3.95.1 5.55.2 Na140139 131138140 K3.13.73.95.24.13.8 GOT20192324 GPT1217 1119 Bilirubin T/D 0.8/0.1 0.3/0.1

12. 11/1711/2612/1812/2312/24 Hb8.810.19.38.8 Hct26.330.028.026.3 MCV8788 WBC8.5110.710.259.3 Platelet106141171146 urine protein 56.8 Urine Cr36.8 RBC0-20-3 WBC2-40-5 Protein(-)30 SpGr1.0071.014 PH55.5 Glucos e -- Cast--

13. 11/2611/2812/23 Haptoglobin< 10 Reticulocyte1.75 (0.5- 1.5) 2.66 Fe34 TIBC205 Ferritin792 AC sugar88 LDH282 Stool O.B.(-)

14. 12/23 RA: < 20 (0-30) ANA: 1:80, speckleAnti-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(-)

16. Renal echo

19. Renal biopsy was done on 97/12/23

21. date97/811/1711/2611/2912/1812/2398/1/51/121/131/14 BUN20377361597476106102101 Cr1.12.873.042.913.764.24.985.55.75.6 Uric acid11.411.0 Total protein6.05.6 albumin3.33.12.9 Cholesterol162139 TG207120 Ca8.28.7 8.6 P3.95.1 5.55.2 Na140139 131138140 K3.13.73.95.24.13.8 GOT20192324 GPT1217 1119 Bilirubin T/D0.8/0.10.3/0.1