Case Conference Department of nephrology R2 우용식

유 O 형 (M/69) adm: C. C. : headache, fever o/s- 4 주전 P. I. :  M/69, 9 월초 headache, febrile sensation 으로 private clinic 에서 po medication 했으나 호전없어 한림대 평촌 성심병원 adm.  Lt. flank pain 으로 abd. CT 로 시행후 Lt. hydronephrosis 보여서 Lt. PCN 시행함.  증상 호전없어서 환자, 보호자 타병원 원하여 비뇨기과 외래 경유 입원.

 PMHx : HTN (-) DM (-) TB (-) Hepatitis (-)  Family Hx. : unremarkable  Personal Hx. : alcohol (-) smoking (-)

Review of systems  General febrile sensation (+) chill(+) : intermittent edema (-) poor oral intake (+)  H & ENT headache(+) dizziness(-) sore throat(-) rhinorrhea(-)  Respiratory cough(-) sputum (-) hemoptysis (-)  Cardiac chest discomfort(-) dyspnea(-) orthopnea(-) palpitation(-)

 Gastrointestinal anorexia(-) nausea(-) vomiting(-) constipation (-) abdominal pain (-) abdominal distention (-) Rt. Flank pain (+)  Genitourinary frequency(-) urgency(-) dysuria(-)

Physical examination  V/S : 140/90mmHg –84/min– 20/min – 36.5°C  G/A : alert, oriented, acute ill looking appearance  Skin : rash (-) pigmentation (-)  H/N : palpable LNs (-), thyroid enlargement (-) neck stiffness (-)  E/E/N/T : isocoric pupil with PLR (++/++) pinkish conjuntiva, whitish sclera PI (-), PTH (-)

 Chest : regular heart beat without murmur coarse breathing sound without rale  Abdomen Soft and distended normoactive bowel sound No hepatosplenomegaly Td / RT (-/-)  Back & extremities CVAT (-/-) pretibial pitting edema (-/-)

Initial lab. data  CBC with diff 12,390/mm 3 – 9.1 g/dL – 30.4% - 501,000/mm 3 (Seg. 86.5%, lym. 7.0%, mono. 4.1%, eosino. 1.5% )  Blood chemistry Total bil./Direct bil. 0.6/0.29 mg/dL Total cholesterol 150 mg/dL ALP/ GGT 375/173 IU/L Protein/Albumin 5.0/2.1 g/dL AST/ALT 42/23 IU/L BUN/Creatinine 17/1.3 mg/dL Na/K/Cl 138/4.0/101 mmol/dL Ca/P 8.8/3.8 mg/dL CRP 10.3 mg/dL

 U/A : RBC many/HPF, WBC many/HPF, protein (3+), blood (2+)

E K G

Initial Chest X-ray

Initial KUB

외부 abd. CT ( )

IVP ( )

Initial Problem list 1.Retroperitoneal fibrosis, idiopathic r/o secondary 2.ARF, post-renal 3.fever

Initial Assessment & Plan 1.A) Retroperitoneal fibrosis, idiopathic r/o secondary P) check 2 nd etiology 2.A) ARF, post-renal P) recheck abd. sono → if need, PCN or DJ stent insertion BUN/Cr level f/u avoid nephrotoxic agent

Initial Assessment & Plan 3.A) fever r/o UTI P) blood culture, urine culture antibiotics ( 외부 병원 antibiotics 사용확인 )

Abd. Sono ( )

Clinical course (10/11) DJ STENT INSERTION, Rt. (10/13) Rt. PCN INSERTION (10/16) Rt. PCN Re-INSERTION Suspende d Rt. Hydro. Rt.PCN self- remove Nephrology transfer

Re- Assessment & Plan 1.A) Retroperitoneal fibrosis, idiopathic r/o secondary P) check medication evaluation hidden malignancy evaluation auto-immune disease 2.A) ARF, post-renal P) evaluation PCN or DJ cathter function use diuretics for pul. edema first, avoid nephrotoxic agent check previous hopital medication

Previous hosp. order review lab  CBC with diff 10,900/mm 3 – 11.9 g/dL – 35.4% - 452,000/mm 3 (Seg. 82.4%, lym. 9.6%, mono. 6.5%, eosino. 1.3% )  Blood chemistry Total bil./Direct bil. 0.6/0.1 mg/dL ALP/GGT 351/143 IU/L Protein/Albumin 6.7/3.9 g/dL AST/ALT 42/23 IU/L BUN/Creatinine 15.6/0.7 mg/dL Na/K/Cl 143/3.7/104 mmol/dL Ca/P 8.7/2.6 mg/dL

Previous hosp. order review-2 Medication  antibiotics levofloxacin 250mg iv (9/28~10/4) ceftriaxone 2.0g iv (10/5~10)  analgesics diclofenac 90mg im (9/23~9/25, 10/4~10/9) ketorolac 30mg iv (10/1~4) Acetaminophen 650mg po tid (10/10)

Clinical course (10/11) DJ STENT INSERTION, Rt. (10/13) Rt. PCN INSERTION (10/16) Rt. PCN Re-INSERTION Suspende d Rt. Hydro. Rt.PCN self- remove Nephrology transfer

Clinical course Ceftriaxone (10/11~13) Ciprofloxacin (10/13~)

Final diagnosis  Idiopathic retroperitoneal fibrosis  Acute renal failure d/t NSAIDS induced  r/o UTI, improved