Case presentation in internal medication examination. See description.

1. 內科專科口試 107年度
姜冠宇 醫師

2. 題號 性別、年齡 主 述 診 斷 CASE有圖片，請
打勾(V)
是本人照顧，請打勾(V)
CASE 1. 41 y/o male; Dyspnea in 2 days. (V) ( )
Acute myopericarditis
CASE 2. 44 y/o Male ; Suddenly onset abdominal pain (V) (V)
Acute pancreatitis with acute respiratory failure
CASE 3. 44 y/o male ; Progress shortness of breath for 1 week (V) (V)
1. Pulmonary tuberculosis with cavitation
2. Acute respiratory distress syndrome
CASE 4. 66 y/o female ; general weakness for 5 days (V) (V)
Hyponatremia
CASE 5. 56 y/o female ; Fever up to 40’C with chills for 1 day (V) ( )
Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
CASE 6. 54 y/o female ; vomiting and diarrhea for 2 months (V) (V)
Lupus enteritis

3. Case 6
54 y/o female with Intermittent vomiting and
diarrhea for 2 months

4. CASE 6. 病例摘要
主訴：
54 y/o female with intermittent vomiting and diarrhea for 2 months
簡單病史：
This 54 y/o woman was a patient of systemic lupus erythematosus, presented with arthralgia lost to follow-up and she had
been admitted on 2016/4/26~4/28 due to infectious diarrhea, urinary tract infection with bilateral hydronephrosis and
esophageal candidiasis.
She suffered from hypoalbuminemia (albumin 2.5) and generalized malaise. She mentioned she had intermittent vomiting
and diarrhea Mar 2016. Weight loss was noted (45>40>32kg) for half a years. The colonoscopy showed multiple polyps and
internal hemorrhoids. The PES revealed reflux esophagitis and esophageal candidiasis. The abdominal CT revealed bilateral
hydronephrosis, diffuse fluid filled distention of most small bowel loop. Lab data showed hypoalbuminemia, hypokalemia
and respiratory alkalosis. Immunologic profile showed ANA >1:2560 Speckled, C3 28mg/dL, C4 15.5mg/dL, anti-ds DNA
20IU/mL (+), anti Sm 128AU/mL (+). She went to ER for albumin infusion. She denied fever or chills, or URI, or UTI symptoms.
There was no oral ulcer, skin rash, photosensitivity, arthralgia or Raynaud's phenomenon. Under the impression of lupus
enteritis, hypokalemia, she was admitted for further management.

5. Chief Complaint
Intermittent vomiting and diarrhea for 2 months
5
Past history suspect SLE 16 years ago, and lost to follow up
Personal history No smoking/No betal nuts/No alcohol
TOCC Denied

6. Patient Illness
Recurred diarrhea
BW 40 → 36 kg, Generalized malaise
Denied fever/chills, URI, UTI symptoms
No contaminated food
ER
2016/03/20
Watery diarrhea for 3 weeks, 10 times/day
Nausea and vomiting 5 times/day
ER
2016/04/25
ER
→ GI OPD
2016/04/11
Still diarrhea
→ PES : candidiasis / Colonscope: polyps
6

7. Physical examination
Conjunctiva: pale(-)
Sclera: anicteric
Pupil: 3.5+ / 3.5+
Head & Neck
Thorax
Thyroid: enlarge(-)
Lymphadenopathy(-)
No oral ulcer
Chest wall: equal chest expansion
Lung: clear,no rhonchi or wheezing
Heart: regular heart beats, no murmurs
Abdomen Tenderness: No muscle guarding
Palpable Mass: nil
Kidney: no flank pain
Bowel Sounds: Normoactive
BP 131/86 mmHg
HR 109 /min
RR 18 /min
BT 36.2℃
Vital sign
Extremities: no pitting edema, Poor skin turgor
No skin rash, No Raynaud's phenomenon.
Others
Cachexia-looking
7

9. CXR 4/25
9

10. Lab data at ER
Na 134 mmol/L
K 2.5 mmol/L
Glucose AC 107 mg/dL
Ca 8.7 mg/dL
BUN 24 mg/dL
Creatinine 0.63 mg/dL
Bilirubin-T. 0.3 mg/dL
AST (SGOT) 27 IU/L
ALT (SGPT) 12 IU/L
HGB 13.9 g/dL
Platelet 248 10 3/μL
WBC 7.96 10 3/μL
Neutrophil 86.6 %
Lymphocyte 10.3 %
Monocyte 2.9 %
Eosinophil 0.1 %
Basophil 0.1 %
ALBUMIN 4/11 3.2 g/dL
ALBUMIN 4/26 2.5 g/dL
10

11. Initial impression at ER
1. Chronic diarrhea
2. Esophageal candidiasis
3. Suspect Systemic Lupus Erythematosus
➔ Arrange abdominal CT
➔ Arrange abdominal echo: Bilateral hydronephrosis
➔ Stool routine, stool culture
➔ Admission
Plan
11

12. PCT 0.19 ng/mL
CRP 2.849 mg/dL
Stool Routine
Appearance soft
Color brown
WBC 1-3
RBC 0-1
Stool OB 3+
Toxigenic C. difficile : NEGATIVE
Lab Data during Admission
12

13. CT Imaging
13

14. Serology markers
ANA >1:2560 Speckled
Anti-dsDNA 20.00 Positive IU/mL
Anti-Sm Ab 128 Positive AU/mL
Anti-Cardiolipin IgG 1.7 Negative GPL-U/mL
Anti-B2-GP1 IgG 2.0 Negative EU/mL
IgG 1980.0 mg/dL
C3 28.0 mg/dL
C4 15.5 mg/dL
14

15. Clinical Course
Still diarrhea → Admission for treatment
Prednisolone 5mg/tab QD
Plaquenil 200mg/tab QD
Empiric antibiotics Unasyn for infection
Rheumatology was consulted for prvious SLE diagnosis
Diarrhea
04/26-04/28
GI OPD refer to
Rheuma OPD
ER refer to
Rheuma (5/11)
15
5/16 Stool Alpha-1 Antitrypsin 10.880 mg/gRecurrent
Diarrhea
05/13-05/23
Methylprednisolone 500mg pulse on 5/19~5/21
Diarrhea improved, discharge on 5/23

16. Final Diagnosis
• Lupus enteritis
○ Protein losing enteropathy
○ Hypoalbuminemia
○ Hyponatremia
○ Hypokalemia
• Esophageal candidiasis
16