This 66-year-old female presented with general weakness for 5 days. She had a history of tongue cancer, diabetes, hypertension, chronic kidney disease stage 3, and hypothyroidism. On examination, she had bilateral lower limb edema and decreased muscle strength. Laboratory tests showed hyponatremia, hypoalbuminemia, and deteriorated renal function. A chest x-ray was unremarkable. She was diagnosed with acute kidney injury exacerbating her chronic kidney disease, along with hyponatremia likely due to diuretics, desmopressin, and poor oral intake. Her condition improved with fluid restriction and discontinuing medications exacerbating her hypotension.

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)
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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) ( )
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CASE 6. The 57-year-old female ; consciousness disturbance and fever for 1 day (V) ( )
Type II diabetes mellitus with hyperglycemic hyperosmolar state

3. Case 4
66 y/o female with general weakness for 5 days

4. CASE 4. 病例摘要
主訴：
General weakness for 5 days
簡單病史：
This 66 y/o female has history of 1. Tongue cancer, pT2cN0 post wide excision on 2016/12/5, post adjuvant RT alone 2.
Type 2 Diabetes Mellitus many years under OADs 3. Hypertension 4. Chronic kidney disease stage III 5. Membranous
nephropathy refractory to steroid, post cyclosporin 6. Hypothyroidism under Eltroxin. She suffered from general weakness
for 5 days. She also complained of poor appetite(+), fatigue(+), nausea(+) and bilateral lower limb edema in recent 2 weeks.
She denied fever, headache, chest pain, dyspnea, abdominal pain, dysuria, decreased urine amount, diarrhea, tarry or
bloody stool. BW loss up to 10kg in recent 3 months was mentioned. She came to our ED for problems above. At ED,
bilateral lower limb edema and decreased muscle powers in four limbs (4+) noticed on physical exam. Lab revealed anemia
(Hb 8.8), Hyponatremia (Na 116 mmol/L), Hypoalbuminemia ( 3.0 gm/dL), deterioration in renal function (BUN /Cr 63 / 3.74
mg/dL). CXR showed no active lung lesion. Under impression of Acute on Chronic Kidney Disease, and Hyponatremia she
was admitted for further management.

5. Chief Complaint
General weakness for 5 days
HTN / DM / MGN with CKD stage 3b under diuretics + ARB
Hypothyroidism under Eltroxin
Tongue cancer stage II s/p wide excision on 2016/12/5, s/p adjuvant RT
Minirin (Desmopressin) for Urinary incontinence
Postan + Augmentin (susp. lower facial defect & cellulitis s/p I & D at OPD)
History
Current OPD medication
Patient

6. Patient illness
Poor appetite(+)
fatigue(+)
nausea(+)
BT：36.2 °C
BP：119/65 mmHg
PR：78 /min
RR：16 /min
Vital Sign

7. Physical Examation
Thorax Chest wall：symmteric expansion
Lung：Breath sounds: bil. clear
Heart：RHB, no audible murmurs
Abdomen Shape：soft and flat
Tenderness：no tenderness
Liver：impalpable
Spleen：impalpable
Kidney：no CP angle knocking
Bowel Sound：normoactive
Others Extremities：pitting edema, 4+
General
Appearance
Development：WNL
Nutrition：obese
Mentality：alert and clear
Cooperation：fair
Head Conjunctiva：pale
Sclera：anicteric
Pupil：3mm/3mm, isocoric
Light reflex：+/+
E.N.T.：n.p.
Neck Thyroid：no goiter
Lymph node：right LAP +

8. CXR

9. Lab data
Na 116 mmol/L
K 5.1 mmol/L
Ca 9.2 mg/dL
BUN 63 mg/dL
Creatinine 3.74 mg/dL
ALT (SGPT) 9 IU/L
Glucose AC 244 mg/dL
HGB 8.8 g/dL
WBC 7.68 10 3/μL
WBC DC
Platelet 427 10 3/μL
Neutrophil 80.7 %
Lymphocyte 9.4 %
Monocyte 8.5 %
Eosinophil 1.3 %
Basophil 0.1 %
ALBUMIN 3 gm/dL
VBG
PH 7.465
PCO2 24.2 mmHg
PO2 98.3 mmHg
HCO3- 17 mmol/L
BE -5.5 mmol/L
O2SAT 97.9 %

10. Lab data
Urine Routine
Specific Gravity 1.015
PH 5
Protein 1+
Glucose +/-
Urobilinogen 0.1 EU./dL
Bilirubin -
Nitrite -
WBC -
P/C Ratio 300 mg/g Cr
Color Yellow
Ketones -
Occult Blood -
RBC 5 /HPF
WBC 5.5 /HPF
Squa.Epithelial cell 4.4 /HPF
Bacteria 0.08 10 5/mL

11. Finial Diagnosis
1. Hyponatremia
○ Desmopressin, diuretics, hypoalbuminemia, poor intake related
2. Acute kidney injury on chronic kidney disease
○ NSAID related
3. Tongue cancer, stage II
○ post wide excision on 2016/12/5, post adjuvant RT
4. Type 2 Diabetes Mellitus, with nephropathy
5. Hypertension
6. Membranous nephropathy refractory to steroid, post cyclosporin
7. Hypothyroidism under Eltroxin

12. Discharged on 8/17.
We encouraged patient to intake more.
The following lab on 8/15 improved
Creatinine(3.74mg/dL → 1.84mg/dL)
Cease Postan Minirin
Water restriction
Hold ARB and Diuretics due to hypotension