1. Case Conference 신장내과 R2 최소영

2. 10236397 박 O 주 (M/82) adm : 06-3-21 C.C) Fevero/s 1 weeks ago P.I ) M/82 30 년전 HTN, 3 년전 Old CVA, BPH Dx, 04 년 APN 으로 입원 치료 받은 자로 1 주 전부터 myalgia, febrile sense 있어 self medication(Tyrenol) 해오던 중 3 일 전부터는 febrile sense 지속되고 poor oral intake 발생하여 응급실 경유 admission PMHx) HTN (+) : 30 년전 DM / TB / Hepatitis (-/-/-) BPH (+) : 3 년전 - a-adrenergic receptor blocker, anticholinergics Old CVA (+) : Rt side weakness, aphasia - antiplatelet agent Op Hx (+) : ’87 carotid-subclavian bypass graft d/t subclavian steal syndrome PHx) Alcohol / Smoking (-/-)

3. Review of Systems General fatigue(+) fever(+) chill(+) Wt. gain(-) Skin rash(-) pigmentation(-) E & ENT visual disturbance(-) diplopia(-) nasal obstruction(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) cyanosis(-) Cardiac angina(-) orthopnea(-) palpitation(-) dyspnea(-) exertional dyspnea(-) G-I A/N/V/D/C (+/-/-/-/-) abdominal pain (-) melena(-) hematochezia(-) Renal oligurina(-) dysuria(-) hematuria(-) incontinence(-) both flank pain(-) urgency(-) fequency(-) residual urine sensation(-)

4. Physical Examination V/S 140/80 mmHg – 88/min – 20/min – 38.7 ℃ General Alert consciousness Chronic ill appearance Skin No rash, No pigmentation Head & neck No Neck vein Engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Slinghtly pale conjunctivae Clear sclerae Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft and flat abdomen No tenderness or rebound tenderness Normoactive bowel sound No hepatosplenomegaly Back/extremity CVA tenderness(+|/-) Pretibial pitting edema(-/-)

5. Initial Laboratory Finding CBC/DC 26040/mm3- 12.87 g/dL –39.2% - 225X10 3 / ㎣ (Seg. 91.2 %) MCV 95.6 fL, MCH32.7 pg Chemistry TB/DB 0.73/0.29 mg/dL AST/ALT 25/15 IU/L ALP/GGT 68/21 IU/L Prot/Alb 5.3/2.2 g/dL LD/CK 421/150 U/L Glucose 123 mg/dL Ca/P/Mg 8.4/4.3/2.5 mg/dL Uric acid 3.9 mg/dL BUN/Cr 37/2.0 mg/dL Na/K/Cl 141/3.9/109 mmol/L UA RBC many/HPF WBC many/HPF Nitrite (+) many bacteria Glucose(-) Protein >300 O.B.:3+ SG: 1.025 Ketone(-) pH: 5.5

6. Estimated CrCl 28.19ml/min FeNa 0.79 FeBUN 26.22 (97 년 ~05.8 월 Cr 1.3~1.6, 05 년 CrCl 45.7ml/min) Lipid profile Total cholesterol : 143 mg/dL Trigalyceride : 96 mg/dL LDL-cholesterol : 76 mg/dL HDL-cholesterol : 43 mg/dL Viral marker HBsAg/HBsAb/HBcAb (-/+/-) Anti-HCV (-)

7. Chest PA

8. Simple abdomen

9. ECG

10. Initial assessment 1. APN 2. Acute on CRF d/t dehydration r/o infection r/o drug 3. BPH 4. Old cerebral infarction 5. HTN

11. Initial Plan 1. APN 2. Acute on CRF d/t dehydration r/o infection r/o drug 3. BPH blood culture urine culture antibiotics Abdominal US if needed IVP, uroflowmetry Hydration, Cr f/u DRE Transrectal US a-adrenergic receptor blocker anticholinergics Residual urine check

12. Abdominal US(06-3-22)

13. IVP(06-3-31)

14. Laboratory Finding Transrectal US(03.4 월 ) : BPH Residual urine check: 0~20ml

15. Clinical Course Ceftriaxone 2g iv qd Hydration 05/8/43/213/233/253/30 Cr1.32.0 1.71.3 CRP14.911.94.20.9 U-WBCmany 10~290~1 BT ( ℃ ) 38.737.936.936.7 Estimated CrCl 45.128.743.37 Blood culture : no growth Urine culture : E. coli