1. 報告者： fellow 1 陳筱惠

3.  Name: 陳 O 綢  Sex: female  Age: 52-year-old  Chart number: 21512475  Date of admission: 2012/01/07

4.  Intermittent gross hematuria about half year

5.  Underlying diseases: hypertension, diabetes mellitus, and chronic kidney disease (stage 5)  Intermittent gross hematuria for about half year  Associated S/S: right flank pain and urinary frequency  No fever, weight loss, abdominal pain, general weakness, poor appetite, nause/vomiting, or dysuria  LMD: treated as UTI initially, then MRI there with liver and right renal tumor

6.  Hypertension, diabetes mellitus, and chronic kidney disease (stage 5)  Urolithiasis: denied  Other significant systemic diseases: denied  Current medicine: anti-HTN medication and OHA from LMD

7.  Allergy: no known allergy  Alcohol: denied; betel-nut: denied; cigarette: denied  Over-the-counter medication or chinese herb: nil

8.  No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

9.  Vital signs: blood pressure: 181/87mmHg; temperature: 36.8‘C; pulse rate: 96/min; respiratory rate: 20/min  General appearance: acute ill looking  Eye: conjunctiva: pale, sclera: no icteric  Neck: supple, no lymphadenopathy or jugular vein engorgement  Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs  Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive  Back: mild right flank knocking discomforts  Extremities: no lower limb pitting edema  Skin: intact, no rash

10. WBC6.2x1000/ul Hgb8.3 g/dl Hct24.5 % MCV90.7 fl PLT241 x1000/uL Segment59 % Creatinine5.11 mg/dl GPT19 IU/L K4.1 mEq/L Sugar162 mg/dl

11. ColorDark yellow TurbidityCloudy SP. Gravity1.014 PH6.0 Leukocyte1+ Nitrite- Protein2+ GlucoseTrace Ketone- Urobilinogen0.1 Bilirulin- Blood3+ bacteria+ RBC>500/uL WBC63/uL Epithelial cell17/uL  01/04 urine culture: mixed flora

12. T1 T2

13. T1 T2

15.  Left kidney Length: 9.4 cm  Right kidney Length: 8.8 cm  1 mixed-echoic mass lesion in the low pole (3.7 cm )  Irregular contour, increased cortical echogenicity with reduced thickness; no pelvocalyceal system dilatation; no obvious renal stone or cyst

16.  1/9 urine cytology: SUGGESTIVE OF MALIGNANCY  1/12 CT guided kidney biopsy: CARCINOMA  BOTH RCC AND TCC ARE POSSIBLE.  1/13 echo guided liver biopsy: POORLY DIFFERENTIATED CARCINOMA, METASTATIC  THE CD10 NEGATIVITY FAVOR IT TO BE OF UROTHELIAL ORIGIN.

17. OriginEmbryologicallyClinicalImmunohistochemically RCC the parenchyma of the kidney, proximal convoluted tubules mesodermal metanephros Clinical triad: <10% patient Paraneoplastic syndrome Positive: vimentin, bcl-2, CD10, LMWCK, CK7 Negative: CK8, CK19, CK20, HMWCK TCC urothelia of the renal pelvis and calices Hematuria: 75% patient Urine cytology: + Positive: LMWCK, CK7, CK8, CK19, CK20, HMWCK Negative: vimentin, CD10

19.  Name: 徐 O 妹  Sex: female  Age: 71-year-old  Chart number: 21511980  Date of admission: 2011/12/29

20.  Bilateral flank pain for several months

21.  Underlying diseases: hypertension, urolithiasis history  Bilateral flank pain for several months  Associated S/S: fever, nausea/vomiting  No abdomial pain, dysuria, or hematuria  LMD: poor renal function (BUN: 80, crea: 9.8) and bilateral renal stone

22.  Underlying diseases: hypertension  Other significant systemic diseases: denied  L‘t renal stone s/p PCWL and R‘t ureteral stone with hydronephrosis s/p DJ  Current medicine: anti-HTN medication from LMD

23.  Allergy: no known allergy  Alcohol: denied; betel-nut: denied; cigarette: denied  Over-the-counter medication or chinese herb: nil

24.  No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

25.  Vital signs: blood pressure: 246/136mmHg; temperature: 36‘C; pulse rate: 88/min; respiratory rate: 17/min  General appearance: acute ill looking  Eye: conjunctiva: mild pale, sclera: no icteric  Neck: supple, no lymphadenopathy or jugular vein engorgement  Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs  Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive  Back: bilateral flank knocking pain  Extremities: no lower limb pitting edema  Skin: intact, no rash

26. WBC8.0x1000/ul Hgb10.9 g/dl Hct34.8 % MCV79.6 fl PLT283x1000/uL Segment73.4 % BUN70.4 mg/dl Creatinine10.23 mg/dl GPT9 IU/L NA138 mEq/L K5.3 mEq/L Sugar107 mg/dl PH7.247 PCO233.1 mmHg PO265.9 mmHg HCO314.1 mm/L SaO290.1 %

27. ColorYellow TurbidityTurbid SP. Gravity1.007 PH6.0 Leukocyte3+ Nitrite+ Protein1+ Glucose- Ketone- Urobilinogen0.1 Bilirulin- Blood2+ bacteria+ RBC5/uL WBC312/uL Epithelial cell1/uL  12/28 urine culture: E.coli

30.  A outpouching mass adjacent right posteior kidney with calcification and suspicious necrotic center, surrounding with few lymph nodes and stranding fat-plane, RCC should be considered first.  Left ureteral stone (0.9 cm in diameter) and left calyceal stones  Bilateral hydronephrosis and bilateral hydroureter with thin renal cortex, suggesting chronic renal impairment. R/O right UP or upper ureter obstruction

33.  Left Kidney Length: 11.4 cm  Hyperechoic lesions with acoustic shadow  Right Kidney Length: 10.7 cm  1 heterogenous mass-like lesion (9.0x5.9cm) with 2 central calficication spot, protruding from upper pole with extention to right suprarenal fossa  The both kidneys are normal in size and contour. The cortical echogenicity and thickness are normal.  No evidence of renal stone or cyst  Mild-to-moderate pelvocalyceal dilatation over the central sinus area of bilateral kidney, with proximal ureteral dilatation

34.  2011/12/28 OP: bilateral DOUBLE-J URETERAL STENT INSERTION  2012/01/05 CT guided kidney biopsy: RENAL CELL CARCINOMA

36.  Name: 陳 O 慧  Sex: female  Age: 27-year-old  Chart number: 20990430  Date of admission: 2012/01/29

37.  Diffuse abdomninal dull pain with fever for 1 week

38.  Ectopic pregnancy history post operation in 2006; Ketamine drug abuser??  Diffuse abdomninal dull pain for 1 week  Associated S/S: fever, dyspnea, dysuria, decreased urine output, nausea sensation

39.  Ectopic pregnancy history post operation in 2006  Significant systemic diseases, like hypertension, diabetes mellitus: denied  Current medicine: nil

40.  Allergy: no known allergy  Alcohol: social drainking; betel-nut: denied; cigarette: 1ppd/day for 8 years  Over-the-counter medication or chinese herb: nil  Ketamine drug abuser??

41.  No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

42.  Vital signs: blood pressure: 142/88mmHg; temperature: 35.4‘C; pulse rate: 112/min; respiratory rate: 25/min  General apperance: acute ill looking  Eye: conjunctiva: mild pale, sclera: no icteric  Neck: supple, no lymphadenopathy or jugular vein engorgement  Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs  Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive  Back: bilateral flank knocking pain  Extremities: no lower limb pitting edema  Skin: intact, no rash

43. WBC18.4x1000/ul Hgb6.4 g/dl Hct22.5 % MCV71.2 fl PLT600x1000/uL Segment88.5 % Sugar144 mg/dl Creatinine7.61 mg/dl GPT57 IU/L Lipase117 IU/L ALK-P984 IU/L Bil (T)0.4 mg/dl NA126 mEq/L K7.8 mEq/L CRP208.02 mg/L PH7.16 PCO222.6 mmHg PO232.1 mmHg HCO37.9 mm/L SaO248 %

44. ColorYellow TurbidityTurbid SP. Gravity1.013 PH8.0 Leukocyte3+ Nitrite- Protein3+ Glucose- Ketone- Urobilinogen0.1 Bilirulin- Blood3+ bacteria+ RBC120/uL WBC>500/uL Epithelial cell12/uL  01/28 urine culture: E.coli

47.  Markedly atrophy of right kidney  Left perinephric fat strandings; enlarged left kidney with heterogeneous parenchymal enhancement; dilated left pelvocalyceal system with strong wall enhancement  Long segmental left ureteral wall thickening with strictures  LNs enlargement at left renal hilum and left para- aortic space  No intraperitoneal free fluid, no extraluminal free air.  Elongated gallbladder without cholecystitis; The liver, spleen, pancreas are unremarkable.

49.  Left Kidney Length: 13.8 cm  Increased echogenicity with prominent and heterogenous papillae  suspect acute papillary necrosis  Right Kidney Length: 0 cm  No evidence of renal stone or mass

50.  Kidney:  Heroin and cocaine  focal segmental glomerulosclerosis (FSGS)  The exact cause of this condition remains in dispute. ▪ Immune-mediated??  Heroin: interstitial nephritis with fibrosis, lymphocytic and plasma cell infiltrates  Cocaine: more renovascular disease and interstitial nephritis than controls The histopathology of drugs of abuse Histopathology 2011, 59, 579–593

51.  Urinary tract:  Ketamine V.S. cystitis ▪ The destruction of the lower urinary tract by ketamine abuse: a new syndrome? BJU Int. 2008; 102; 1616–1622. ▪ 59 patients with lower urinary tract symptoms ▪ 12 patients had bladder biopsies.  cystitis with denudation of the urothelium, granulation tissue in the lamina propria and an infiltrate predominantly of lymphocytes with variable eosinophils