1. Problem Case 경희의료원 신장내과 R1 진상욱 경동맥 스텐트 삽입 후 크레아티닌 수치가 증가한 64 세 남자 환자

2. Chief Complaint 신장 기능이 많이 떨어졌대요. Present Illness 07 년 6 월 22 일 우측 쇠약감으로 본원 신경과에서 뇌경색과 동반된 양측 경동맥 협착증 진단받고 헤파린과 플라빅스 투약 후 증세 호전 되어 퇴원한 환자로 07 년 7 월 15 일 본원 신경외과에서 좌측 경동맥 스텐트 삽입 후 신기능감소 있어 이에 대한 검사 및 치료 위해 전과 00711381 오 O 본 M/64 Admission on 07-8-14

3. Past medical historyPast medical history DM/HTN/Tb/HB (+/+/-/-) DM : 5-6 년 전 진단 medication : Voglibose (a-glucosidase inhibitor) HTN : 2-3 년 전 진단 medication : Nifedipine (calcium channel blocker) *Aprovel (angiotensin II receptor blocker) CKD : 타 병원에서 3 년 전 우연히 알게 되었음 BPH : Doxazosin 복용 중 Personal history Smoking : 하루 1 갑 x 40 년 ( 현재 금연상태 ) Alcohol : 매일 소주 1~2 병 x 40 년 ( 현재 금주상태 )

4. Review of System General fatigue (+) febrile sense (-) weight change (-) edema (+) Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) Eyes & ENT visual disturbance (+) : 4-5 년 전부터 시력 저하 발생 Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5. Review of System Gastrointestinal epigastric discomfort (+) : 식사 후 속 쓰림 호소함. A/N/V/D/C (+/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) Urinary Urinary dysuria (-) frequency (+) urgency (+) RU sense (+) Musculoskeletal numbness (+) : both lower extremities Neurologic syncope (-) seizure (-) dizziness (-)

6. Physical Examination Vital sign 134/77 – 89 회 /min – 20 회 /min - 36°c General alert mentality chronically ill-looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT isocoric pupil with PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

7. Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and flat normoactive bowel sound tenderness (-) rebound tenderness (-) no palpable mass no abdominal bruit no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (+/+)

8. Initial Lab Findings (8/14) CBC/DC 9300/mm² -11.4 g/dl – 33.2%- 417K (seg : 63.0%, eosinophil count : 12%) aPTT 38.4/34 sec INR 1.14 ESR 60 mm/hChemistry TB 0.3 mg/dL AST/ALT 10/10 U/L ALP/GGT 140/44 U/L Prot/Alb 7.1/3.9 g/dL LD/CK 378/76 U/L BUN/Cr 81/7.1 mg/dL Na/K/Cl 136/5.6/100 mmol/L CRP 2.21 mg/dL HbA1c 6.7% Cholesterol 208 mg/dL HbA1c 6.7%U/A RBC 2-4/HPF WBC 30-50/HPF Protein (1+) Lipid profiles TG 163 mg/dL HDL 26 mg/dL LDL 145 mg/dL

9. Change in 1/Creatinine Level Change in 1/Creatinine Level 7 월 25 일 Lt. ICA stent insertion (NS) 6 월 22 일 cerebral angiography 시행 (NR)Date6/226/287/187/257/278/14 serum creatinine 2.22.33.02.73.27.1

10. EKG

11. Chest PA

12. Problem List 1. increased creatinine level in a CKD patient 2. hypereosinophilia 3. increased ESR and CRP 4. generalized edema 5. pyuria 6. proteinuria 7. DM 8. HTN 9. BPH 10. CVA with both proximal ICA stenosis s/p angioplasty and stent insertion

13. Initial Assessment #1. acute exacerbation on CKD d/t cholesterol crystal embolism d/t r/o radio-constrast toxicity d/t r/o renal artery stenosis d/t r/o obstructive uropathy by BPH d/t r/o urinary tract infection d/t r/o volume depletion d/t r/o systemic vasculitis #2. DM #3. HTN #4. CVA with both proximal ICA stenosis s/p angioplasty and stent insertion

14. Diagnostic Plan 1. Follow up eosinophilic count 2. Check C3/C4 level 3. Check creatinine level 4. Abdominal ultrasonography 5. MR angiography 5. Urine culture 6. Fundoscopy 7. Serologic marker

15. Therapeutic Plan Maintain volume and electrolyte balance Maintain volume and electrolyte balance Nutritional support Nutritional support Dialysis Dialysis

16. Abdominal USG

17. MR Angiography

18. Serial Creatinine Level Date6/226/287/187/257/278/148/218/28 serum creatinine 2.22.33.02.73.27.17.612.7

19. Blue toe syndrome

20. Livedo reticularis

21. Skin biopsy at Lt. toe : no cholesterol clefts Skin biopsy at Lt. toe : no cholesterol clefts Other Diagnostic Workup

22. Clinical Progression Clinical Progression 7 월 25 일 Lt. ICA stent insertion (NS) 6 월 22 일 cerebral angiography (NR) 8 월 28 일 HD 9 월 20 일 PDDate6/227/188/148/218/288/309/209/23 Creatinine level 2.23.07.17.612.710.68.88.6 Eosinophil count (%) 7.410.012.016.517.316.611.16.1

23. Final Diagnosis Subacute cholesterol crystal embolism