1. case conference case conference Department of nephrology R2 하상진 2006. 05. 8.

2. ID number; 11516318 Sex/Age; Female/57  C. C. : abdominal discomort Onset : 3 days ago  P. I. :Cb infarction,HTN, s-colostomy d/t s colon perforation 로 Rt hemiparesis, s-colostomy 하고 있으며 05.8 chronic cystitis d/t bladder stone 으로 URO OPD f/u 하는 환자로 내원 3 일전부터 abdomial discomfort 있어 약국에서 소화제 먹고 지내던 중 nausea & vomiting 있으면서 증상 심해져서 local clinic 방문 r/o acute perforation, pancreatitis 의심하에 큰 병원 권유 받아 전원되어 ER 방문. Present Illness (1)

3.  PMHx. : HTN (+) DM (-) TB (-) viral Hepatitis (-) CB infartion ; 00 (Lt ICA bridge) chronic cystitis d/t bladder stone ; 05.8 op. Hx (+) 00.12 1°closure & S-loop colostomy 02.3 Fx intertrochanter femur Rt 04.7 rectovaginal fistula, dermoid cyst excision op 중 S-colon perforation repair  Family Hx. : unremarkable  Personal Hx. : alcohol (-) smoking (-) Present Illness (2)

4. General fever(-) chill(-) fatigue(+) myalgia(-) skin rash(-) H & ENT headache(-) dizziness(-) sore throat(-) neck stiffness(-) Respiratory cough(-) sputum (-) hemoptysis (-) Cardiac chest discomfort(-) dyspnea(-) orthopnea(-) palpitation(-) Gastrointestinal anorexia(+) nausea(+) vomiting(+) diarrhea(-) constipation(-) abd pain(+) Genitourinary frequency(+) urgency(-) dysuria(-) Musculoskeletal arthralgia(-) Review of systems

5. V/S : 100/60mmHg –104/min– 24/min – 36.5°C G/A : alert, oriented, acutely 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 & rapid heart beat without murmur clear breathing sound without crackle Physical examination

6. Abdomen Soft and obese Normoactive bowel sound No hepatosplenomegaly Td / RT (+/-) Muscle guarding(-), s-colostomy Back & extremities CVAT (+/-) no pretibial pitting edema Neurology Motor ; Rt hemiparesis Babinski sign (-/-) Physical examination

7.  CBC with diff 11,290/mm 3 – 14.1 g/dL – 42.8% - 177,000/mm 3 (Seg. 86.2%)  ESR / CRP 70 mm/hr / 24.8 mg/dL  PT(INR) /aPTT 1.22 / 60 c 33  Blood chemistry Total bil./Direct bil. 0.87/0.11 mg/dL ALP/ GGT 58/14 IU/L Protein/Albumin 5.6/2.5 g/dL AST/ALT 20/26 IU/L LDH/CK 389/43 IU/L BUN/Creatinine 49 /2.8 mg/dL Na/K/Cl 141/3.8/108 mmol/dL Glucose 744 mg/dL Initial lab. data

8.  U/A : RBC 0~1/HPF, WBC many/HPF, many bacteria, many yeast  Spot urine Creatinine 118.6 mg/day Urea nitrogen 628 mg/day K / Cl / Na 42.6/14/9 mmol/day  Fe Na 0.15  Fe Urea 30.25 % Initial lab. data

9. E K G

10. Initial Chest X-ray

11. Initial simple abd

12. # 1. Abdominal pain c CVA Td Rt # 2. Hypotension # 3. ARF # 4. hyperglycemia # 5. known bladder stone # 6. s/p s-colon perforation with colostomy # 7. old CVA # 8. s/p Fx intertrochateric femur Rt Initial Problem list

13. Initial Assessment & Plan # 1. abdominal pain #2.hypotension A > APN, urosepsis D. P. > blood CX, urine CX abdominal ultrasonography T. P. > antibiotics (ceftriaxone 2.0g iv qd) fluid resuscitation & inotropics # 3. ARF A> prerenal ARF or postrenal ARF D.P.> abdominal ultrasonography T.P.> 1.hydration & electrolyte, BUN/Cr F/U correct systemic condition 2.correct postrenal condition

14. Initial Assessment & Plan # 4.hyperglycemia A> DM P> check HbA1c & GMT intensive glycemic control using insulin # 5. known bladder stone # 6. s/p s-colon perforation with colostomy # 7. old CVA # 8. s/p Fx intertrochateric femur Rt

15. Clinical course (HD #2) S > fever (+) chilling(+) dyspnea (-) O > V/S :80/50mmHg –120/min– 24/min – 39°C Lab CBC/DC 7,810/mm 3 – 13.1 g/dL – 41.9% - 94,000/mm 3 (Seg.80.2%) BUN/Creatinine 36/1.9 mg/dL U/A : RBC 0~1/HPF, WBC many/HPF, many yeast abd sono ; Mass in collecting duct in Rt kidney with hydronephrosis (next slide)

16. Abdominal US

17. A > Urosepsis d/t yeast more likely P> Rt Percutaneous nephrostomy confirm PCN site culture & urine culture 확인 increase Itraconazole to 400mg iv qd inotropics 유지 & 증량 abdominal CT Clinical course (HD #2)

18. Percutaneous Nephrostomy

19. Chest CT

20. Clinical course (HD #9) S > fever (+) chilling(-) dyspnea (-) O > V/S :130/80mmHg –97/min– 18/min – 38°C Lab : CBC with diff 7,760/mm 3 – 11.9 g/dL – 33.1% - 82,000/mm 3 (Seg. 80.2%) CRP 24.9 mg/dL U/A : RBC 0~1/HPF WBC 5~9/HPF, moderate yeast blood culture ; candida albicans urine culture ; candida albicans A >Candida pyelonephritis Urosepsis P> itraconazole 400mg iv qd 로 증량 tubogram & cytology

21. Tubogram

22. Clinical course (HD #19) S > fever (+) chilling(-) dyspnea (-) O > V/S :110/70mmHg –94/min– 20/min – 38°C Lab CBC/DC 7,760/mm 3 – 11.9 g/dL – 33.1% - 82,000/mm 3 (Seg. 70.4%) CRP 13.1 mg/dL U/A : RBC 0~1/HPF WBC many/HPF blood culture (HD# 16); no growth urine culture (HD# 16); MRSA tubogram cytology & biopsy ; Kidney, ureteropelvic junction, right, biopsy: Fungal infection, consistent with candidiasis IVP (AGP) ;next slide

23. IVP (AGP)

24. A > Urosepsis improved state APN known bladder stone P> add vancomycin 1g iv q 12hrs urine culture f/u consult URO for stone removal Clinical course (HD #19)

25. A-AXON Itraconazole 200mg qd A-vanco PCNcytology Itraconazole 400mg qd 2.82..11.5 0.9 creatinine

26. Uncontrolled DM HbA1c;15.1% FBS33343030016710895 110120 PP2hr372371183 143170148150156 RI slidinng I-INGA + slidinng I-INGA + HUMA*3

27. Final diagnosis # 1.Urosepsis d/t fungal ball at UPJ # 2. uncontrolled DM # 3. known bladder stone # 4. s/p s-colon perforation with colostomy # 5. old CVA # 6. s/p Fx intertrochateric femur Rt