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

3. Case 2
44 y/o Male with Suddenly onset abdominal pain

4. CASE 2. 病例摘要
主訴：
Suddenly onset abdominal pain
簡單病史：
This 44-year-old man had a past history of acute appendicitis s/p appendectomy. He was suddenly onset abdominal pain
since 2017/05/04. After medical treatment, the symptom was not subsided. Thus, he was brought to our ER for help on
2017/05/11 where increased lipase, leukocytosis, hypocalcemia and tachycardia was noted. he denied nausea/vomiting,
fever, and body weight loss. NPO, IV hydration, antibiotic treatment with flumarin were given. Abdominal echo related
fatty liver, moderate, ascites and pleural effusion on 05/12. As the diagnosis of acute pancreatitis, he was admitted for
further evaluation and treatment.

5. Chief Complaint
Sudden onset abdominal pain since 2017/05/04
Diened nausea/vomiting, No body weight loss
Past history
Drinking (+) Sorghum, social
Acute appendicitis s/p appendectomy
5
Patient

6. Physical examination
Conjunctiva: pale(-)
Sclera: icteric
Pupil: 3.0+ / 3.0+
Head & Neck
Thorax
Thyroid: enlarge(-)
Lymphadenopathy(-)
Chest wall: equal chest expansion
Lung: clear,no rhonchi or wheezing
Heart: regular heart beats, no murmurs
Abdomen Tenderness: Peri-umbilical tenderness
Palpable Mass: nil
Kidney: no flank pain
Bowel Sounds: Hypoactive
Extremities: no pitting edema
Peripheral Pulse: +
Others
6
BP 161 / 100mmHg
HR 106 /min
RR 20 /min
BT 37 ℃

9. Lab data at ER
9
HGB 15.3 g/dL
HCT 43.3 %
MCV 90.5 fL
WBC 19.55 10 3/μL
WBC DC
Platelet 229 10 3/μL
Neutrophil 84 %
Lymphocyte 8 %
Monocyte 7 %
Band 1 %
Na 127 mmol/L
K 3.6 mmol/L
BUN 23 mg/dL
Creatinine 0.79 mg/dL
Bilirubin-T. 1.3 mg/dL
AST (SGOT) 26 IU/L
Glucose AC 142 mg/dL
LIPASE 1157 IU/L
Amylase Not approach
LDH 531 IU/L

10. Initial impression at ER
1. Acute alcoholic pancreatitis
2. Hyponatremia
10
At Ward
輸入合計 3220.0 8786.0 9949.0 4792.0 4080.0 3330.0
輸出合計 1200.0 2500.0 1310.0 1780.0 2800.0 3900.0
量差 +2020.0 +6286.0 +8639.0 +3012.0 +1280.0 -570.0
* Dyspnea and desaturation

11. CXR 5/15

12. Lab data at Ward
Na 130 mmol/L
K 4.2 mmol/L
Cl 97 mmol/L
Ca 6.7 (*7.8) mg/dL
BUN 38 mg/dL
Creatinine 4.38 mg/dL
GFR 15
Triglyceride 1209 mg/dL
CPK 115 IU/L
CK-MB 28 U/L
TROPONIN-T 27.0 ng/L
ALBUMIN 2.6 gm/dL
Ammonia 36 umol/L
Lactate 1.11 mmol/L
AST(GOT) 32 IU/L
ALT (GPT) 15 IU/L
Amylase 40 IU/L
LIPASE 89 IU/L
ABG
PH 7.124
PCO2 65.8 mmHg
PO2 67.5 mmHg
HCO3- 21.1 mmol/L
BE -9.3 mmol/L
O2SAT 86.3 %
FIO2 1.000

13. Lab data at Ward
HGB 12.2 g/dL
Hct 26.6 %
Platelet 176 10 3/μL
INR 1.17
APTT 41.8 sec
PT 12.1 sec
WBC 11.73 10 3/μL
WBC DC
Neutrophil 79.0 %
Lymphocyte 7.0 %
Monocyte 7.0 %
Eosinophil 1.0 %
Basophil 0.0 %
Band 3.0 %

14. Diagnosis
1. Acute pancreatitis with acute respiratory failure
2. Acute kidney Injury
3. Hypertriglyceridemia
➔ NPO and IV supplement
➔ Shift antibiotic Flumarin to Tienam
➔ Ventilator setting
➔ Added Fenofibrate
Plan
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