1. Case Conference 신장내과 R2 우종신

2. 11688884 한스 0 자 (F/69) adm : 06-2-28 CC ) Poor oral intake (onset: 15days ago) P.I ) 2005 년 12 월 TKR Rt 받은 Hx 있는 자로, 당시 Cr = 1.8mg/dL 로 이상소견 발견하였으며, 수술후 fever 지속되어 antibiotics(ceftriaxone, clindamycin) 투여 후 Cr 증가 소견 보여, 2006 년 1 월 본원 외래 방문하여 F/U 중 15 일 전부터 poor oral intake, vomiting 있어 OPD 통해 입원함.

3. PMHx : DM /HTN/ TB / Hepatitis (-/-/-/-) Op Hx (+) 2005 년 12 월 TKR Rt travel Hx (-), drug Hx (+) : antibiotics FHx DM(-) HTN(-) renal disease(-) Personal Hx : Alcohol / Smoking (-/-)

4. 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(-)

5. Physical Examination V/S 130/80 mmHg – 90/min – 19/min – 36.3 ℃ B.W) 58kg Height) 152cm BMI) 25.1kg/m2 General Alert consciousness acutely ill-looking appearance Skin No rash, No pigmentation Head & neck No Neck vein Engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Slinghtly pale conjunctivae Clear sclerae Dehydrated tounge 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(-/-)

6. Initial Laboratory Finding CBC/DC 7410/mm3- 11.6 g/dL – 35.4 % - 519X10 3 / ㎣ (Seg. 96.1 %) MCV 83.4 fL, MCH 27.3 pg Chemistry TB/DB 0.80/0.09 mg/dL AST/ALT 14/8 IU/L ALP/GGT 54/12 IU/L Prot/Alb 8.0/3.8 g/dL LD/CK 347/41 U/L Glucose 98 mg/dL Ca/P/Mg 10.7/7.0/2.5 mg/dL Uric acid 15.8 mg/dL BUN/Cr 47/6.3 mg/dL Na/K/Cl 130/5.2/98 mmol/L UA RBC many/HPF WBC 2-4/HPF O.B.:3+ Ketone(-) Glucose(-) Protein(-) SG: 1.025 pH: 5.5

7. Lipid profile – Total cholesterol : 239 mg/dL Trigalyceride : 219 mg/dL LDL-cholesterol : 172 mg/dL HDL-cholesterol : 21 mg/dL Viral marker – HBsAg/HBsAb/HBcAb (-/+/-) Anti-HCV (-) anti-HAV lgM (-)

8. Chest PA

9. Simple abdomen

10. ECG

11. Problem list 1. Poor oral intake, nausea, vomiting 2. Azotemia 3. Hyperuricemia 4. Hematuria 5. Hypercholesterolemia 6. s/p TKR Rt

12. Initial Assessment Acute on chronic renal failure due to dehydration R/O drug or toxin R/O urologic abnormality R/O underlying malignancy Hematuria due to R/O stone R/O underlying malignancy

13. Initial Plan 1. Spot urine chemistry (Na, Cl, Creatinine, urea nitrogen) -> FeNa Serologic markers (IgA, IgE, IgG, IgM, C3, C4, RF, ANCA ANA, RF, ASO, Cryoglobulin) RBC morphorlogy 24hr urine collection abdominal US IVP If needed, renal biopsy

14. Laboratory Finding Spot urine chemistry 24hr urine collection Na 89 Protein 190 mg/day urea nitogen 465 Creatinine 621 mg/day Creatinine 129.4 Urine volume 2370 mL/day FeNa 3.34 CrCl 6.2 mL/min FeBUN 41% Uric acid 289 mg/dL Ca 206 mg/day Urine RBC morphology <5% MCV non glomerular Serologic markers IgG 2810 mg/dL IgA 397 mg/dL IgM 75.9 g/dL IgE 109 mg/dL C3 114 mg/dL C4 19.2mg/dL C-ANCA (-) P-ANCA (-) ANA (-) RF<9.5 IU/mL ASO 1250 IU/Ml (< 200) Cyoglobulin (-)

15. Abdomen US

16. Clinical Course I Fliud challenge & diuretics for 7 days 2/283/13/23/33/43/53/6 BUN/Cr47/6.355/6.350/5.940/5.132/4.928/4.729/4.6 Uric acid15.815.113.211.211.310.510.9 Input Output 700 200 4150 2420 3650 3150 3500 2950 4150 3860 3300 3250 3900 3360

17. Percutaneous Nephrostomy(2006.3.6)

18. Clinical Course II 3/63/73/83/93/103/113/12 BUN/Cr29/4.623/3.528/3.035/2.4 Uric acid10.98.2 7.2 Input Output Nephro 3900 3360 450 2910 3600 3300 1200 1950 3050 3300 1200 2080 3250 3150 2150 1000 2350 2870 1970 900 2200 2700 1600 1100 3900 3360 Nephrostomy and hydration

19. Final diagnosis Acute on chronic renal failure due to dehydration with partial ureter obstruction