Department of nephrology R1 이윤정 Case Conference Department of nephrology R1 이윤정
HISTORY 김*환 (M/59) Admission date: 05.06.03 Chief Complaint) Anorexia remote onset:약 1년전 recent onset :1주일전 Present Illness) 10년전부터 HTN으로 medication하던 59세 남자로 내원 4-5년 전부터 Lt. 1st toe, both ankle의 arthralgia로 self로 intermittent하게 p.o.medication했었고, 내원 1년전부터 anorexia, fatigue 있었지만 , 특별히 evaluation하지 않고 지내다가 내원 약 1주일 전부터 Sx. 심해져서 05.05.31 local에서 시행한 lab에서 BUN/Cr. 102.9/11.7소견 보여서 further evaluation 및 manage 위해서 OPD통해 admission함
HISTORY Past medical Hx) DM/HTN/TBc/Hepatitis(-/+/-/-) : norvasc 5mg p.o qd OP Hx. (-) Family Hx) none Personal Hx) alcohol (+) : social drinking smoking(-)
REVIEW of SYSTEMS General : fatigue(+), fever(-) chill(-) sweating(-), wt.loss(+):80kg72kg/1year H & N : headache(-) neck stiffness(-) Chest : dyspnea(-) chest pain(-) palpitation(-) cough(-) sputum(-) GI : A/N/V/D/C(+/+/-/-/-) abdomial pain(-) melena(-) , hematochezia (-) Renal : dysuria (-) hematuria (-) frequency (-) Musculoskeletal : edema(-) swelling(-) joint pain (+): both 1st toe,ankle Nervous : seizure(-) stroke(-) dizziness(+)
Physical Examination V/S ) 140/80mmHg-76회/min-19회/min-36.6°C General : alert consciousness not acute- ill looking appearance 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 , whitish sclerae Chest : clear breath sound without rale regular heart beat without murmur Abdomen : soft and flat abdomen , abdominal Td/RT(-/-) abdominal palpable mass(-) , normoactive B.S. B/Ext : CVA tenderness(-/-) pitting edema(-/-)
Impression CRF d/t HTN R/O ARF Known HTN R/O Gout R/O inflammatory arthritis
Plan CBC/DC, PT/PTT, Chemistry , U/A , ABGA Abd.sono , 24hr urine collection PTH, BDM , Both foot , ankle , knee AP/Lat. Gastroscopy 고려
Lab Finding CBC/DC : 7140/mm3-9.7 g/dL-28.5%-200K (seg 74.7%) INR 1.13 aPTT 33C33 Chemistry: TB/DB 0.4/0.1 mg/dL AST/ALT 12/9 U/L ALP/rGT 55/16 mg/dL Prot/alb 7.6/3.8 g/dL LD/CK 402/335 U/L Glucose 212 mg/dL BUN/Cr 139/14.6 mg/dL Ca/P 6.6/7.0mg/dL Na/K/Cl 139/4.9/117mmol/L Uric acid 11.9 mg/dL Cholesterol 141mg/dL TG 251 mg/dL CRP 1.0mg/dl (<0.5) ABGA (R.A ) : 7.179-21.3-112.3-7.8-97.1%
Lab Finding U/A : RBC 5-9/HPF, WBC 0-1/HPF, Protein(-) PH 5.0 Specific gravity 1.015, Occult blood (-) 24hr urine collection protein 525mg/day creatinine 833mg/day urea nitrogen 2797mg/day Crcl 8.6ml/min Viral marker HBs ag (-) anti - HBs ab (+) anti - HBc ab (+) HIV (-) HCV(-) Chest PA : No active lung lesion EKG : NSR
Abdominal sono
Foot , knee
PCN (Percutaneous nephrostomy)
Clinical course HD START PCN시행 HD Stop
Clinical course PCN 시행
Clinical course 내원시 dual lumen catheter insertion (Rt.int.jugular vein) HD 시작함 (05.06.03-05.06.15) HD 이후 증상 호전되는 양상보임 PCN 시행함(05.06.08) 이후 Urine output 증가하고 , creatinine 증가하지 않아서 HD stop함. 비뇨기과 상의후 PCN 유지하기로 하고 추후 OPD F/U 하면서 stone remove에 대해 결정하기로 함. Chronic gout 소견 보여 allopurinol po , low dose steroid injection 시행함. OGTT 시행 : FBS 120 mg/dl , 1hr 214mg/dl ,2hr 265mg/dl DM 진단하여 diamicron 40mg, qd 복용함.
Final diagnosis Acute on CRF d/t obstructive nephropathy (stone) Chronic Gout Type 2 DM Known HTN