1. Problem case Dep. Of Nephrology R1. Choi In-Ah arteriovenous graft site 의 redness 와 swelling 을 주소로 내원한 52 세 남성

2. History Chief complaint: Lt upper arm redness and swelling (onset: 9 days ago) Present illness M/52, ’89 HTN CRF 진단. ’94 년 ESRD 진단 후 HD 시행 중인 자로 최근까지 사용하고 있던 Lt arm 의 brachio-cephalic AV graft, PTFE 부위 redness 와 swelling 발생하여 AKU 통해 경구 항생제 (cefaclor 250mg tid) 1 주간 복용하였으나 증상 지속되어 외래 통해 입원 11852528 신 0 천 M/52 Adm:06-10-10

3. Past medical history DM/ HTN/ Hepatitis/ Pulmonary Tb (-/+/-/-) ESRD on HD since ’94 LV heart failure(+) d/t cardiomyopathy OP Hx:’94.12.21 Lt radio-cephalic AVF ’02.4.1 AVF revision with PTFE ’06.7.31 Lt brachio-cephalic with PTFE Personal history Smoking (-)alcohol (-) History (con’t)

4. Review of system  General : fatigue (-) fever (-) chill (-) Malaise (-)  Skin : rash (-) itching (-) pigmentation (-)  H & N : headache (-) sore throat (-) visual opacity (-)  Chest : chest pain (-) palpitation (-) cough (-) sputum (-) dyspnea (-)  GI : A/N/V/D/C (-/-/-/-/-) abdominal pain (-)  Urinary : anuria (+)  Musculoskeletal : leg pain (-) LBP (-) AV graft Lt, distal part tenderness (+) AV graft Lt, middle part pulsation (+)

5. Physical Examination  V/S 130/80 mmHg-70 회 /min-20 회 /min-36.1 °C  Height 173 cm BW 63 Kg BMI 21 kg/m 2  General alert mentality  SKIN no rash no pigmentation  H/N no thyroid gland enlargement no cervical LN enlargement no neck vein engorgement  E/ENT isocoric pupil with PLR(++/++) pinkish conjunctiva with clear sclerae  Chest clear breath sound without rale regular heart beat without murmur

6.  Abdomen soft and flat abdomen abdominal Td/RT(-/-) hypoactive B.S. shifting dullness(-)  B/Ext CVA tenderness(-/-) pitting edema(-/-) Lt upper arm redness(+) swelling(+) heating sensation(+) Lt lower arm: previous OP scar (+) Physical Examination (con’t)

7. Initial Lab Finding (10/2 AKU)  CBC/DC :6350/mm3-9.2g/dL-27.5%-279K INR 1.84 aPTT 21.1 sec  Chemistry : BUN/Cr 20/5.5 mg/dL Na/K 136/4.1 mmol/L Uric acid 8.4 mg/dL Prot/alb 6.8/3.7 g/dL AST/ALT 16 / 9 U/L Ca/P/Mg 8.2/3.3/1.5 mg/dL CRP/Glu 2.2/108 mg/dL

8. EKG

9. Chest PA

10. 1. Redness, swelling of the Lt AV graft, distal part 2. ESRD on HD 3. Known cardiomyopathy Initial problem lists

11. 1. Redness, swelling of the Lt AV graft, distal part A) graft infection d/t improper handling P) blood culture, wound culture, ESR, CRP antibiotic agent extremity doppler sonogaphy emergency graft removal Initial Assessment & Plan

12. 2. ESRD on HD A) ESRD on HD, d/t HTN CRF P) keep hemodialysis 3. Known cardiomyopathy A) LV failure with cardiomyopathy P) digoxin, ACE inhibitor Initial Assessment & Plan

13. Extremity sonography (10/10) Lt graft transverse viewLt graft longitudinal view

14. 1. Redness, swelling of the Lt AV graft, distal part 2. ESRD on HD 3. Known cardiomyopathy + 4. Pulsation of the Lt AV graft, middle part Problem lists

15. 4. Pulsation of the Lt AV graft, middle part A) pseudoaneurysm at puncture site P) thrombin injection guided by doppler sonography manual compression guided by ultrasonography mechanical compression, if needeed Additional Assessment & Plan

16. Extremity Doppler (10/13)

19. Extremity Doppler (10/13)(10/10)

21. Clinical course 10/1 10/2 10/3 10/4 10/5 10/6 10/7 10/8 10/9 10/10 10/11 10/12 10/13 10/14 10/15 admission Sx onset Vascular doppler : Perivascular inflammation with fluid collection blood culture Vascular doppler : improved fluid collection pseudoaneurism cefaclor 250mg tidceftezole sodium 1g bid Enterococcus gallinarum compression

22. Culture  Blood Culture (1/1) : Enterococcus gallinarum: O07320 ent,