Department of nephrology R1 이동영

Presentation on theme: "Department of nephrology R1 이동영"— Presentation transcript:

1 Department of nephrology R1 이동영
Case Conference Department of nephrology R1 이동영

2 HISTORY 11734875 배O례 F/48 Admission : 06.01.19
Chief Complaint : Fever (onset:1day ago) Present Illness :10년 전부터 DM, HTN으로 medication하는 자로 2004년 8월 fever에 대해 ADPKD cystic infection 진단 받았고 당시 tube drainage 및 항생제 투여 받았음. 내원 1일 전 Lt. flank pain, fever 발생해 응급실 통해 비뇨기과로 입원함.

3 HISTORY Past medical Hx Family Hx Personal Hx alcohol (-) smoking(-)
DM/HTN/TBc/Hepatitis(+/+/-/-) DM-humulin:26/10 IU HTN : anydipine 5mg qd OP Hx. (-) Family Hx Personal Hx alcohol (-) smoking(-) ADPKD ESRD, KTP후 expire

4 REVIEW of SYSTEMS General : fatigue(+) fever(+) chill(+) Malaise(+)
H & N : headache(-) sore throat(-) Chest : dyspnea(-) chest pain(-) palpitation(-) cough(-) sputum(-) GI : A/N/V/D/C(-/-/-/-/-) abdominal pain(-) melena(-) hematochezia (-) Renal : dysuria (+) frequency (+) hematuria (-) voiding difficulty(+) Musculoskeletal : edema(-) swelling(-) Nervous : seizure(-) stroke(-)

5 Physical Examination V/S 110/70mmHg-100회/min-20회/min-38.0°C
General : alert consciousness 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 crackle 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(-/-)

6 Impression APN, r/o infected cyst Known ADPKD Known DM Known HTN

7 Plan CBC/DC, PT/PTT, Chemistry , CRP U/A , FENA,FEUN, ABGA
Blood & urine culture Abd.sono

8 Lab Finding FENA=15.32,FEUN=100
CBC/DC :9530/mm g/dL % - 175K/ mm3 (seg 84.8%) INR aPTT 35C33 Chemistry: TB/DB /0.03 mg/dL AST/ALT 22/16 U/L ALP/rGT 44/16 mg/dL Prot/alb /3.5 g/dL BUN/Cr 25/1.9 mg/dL Ca/P /2.5mg/dL Na/K/Cl 138/4.2/105 mmol/L U/A : RBC 5-9/HPF, WBC Many/HPF, Protein(-) PH Specific gravity 1.025, Occult blood (3+) Chest PA : No active lung lesion EKG : NSR FENA=15.32,FEUN=100

9 Previous admission Clinical course(2004-8-30)
한 달 전부터 시작된 fever, Rt flank pain으로 서울성심병원에서 ADPKD 진단받고 항생제 치료 받았으나 호전 없어 본원 내원 Ampicilline + Tobramycin  Ciprofloxacin + Tobramycin 본원에서 bactrim으로 교체 후 Nausea, Vomiting 심해 약 D/C후 Ciprofloxacin투여 이후 열 지속되고 CT에서 infected cyst 의심되어 URO전과 후 drainage tube insert 및 항생제 치료 받고 퇴원

10 Previous admission Abd CT

11 Previous admission tube drainage and sclerotherapy

12 Abdominal sono(1.20)

13 Clinical course Cefotiam 투여 Ciprofloxacin투여

14 Clinical course

15 Clinical course 내원시 APN, Lt R/O cyst infection
 항생제 투여시작(Cefotiam 1g bid iv) ( ~)  항생제 투여 해도 임상증상, Lab 호전 없고 Cr ↑하는 acute on CRF 보여서 내과로 전원. Blood & urine culture에서 E.coli 관찰되었고 지속되는 증상에 대해 cyst infection 의심되어 항생제 변경( ~) : Cefotiam  Ciprofloxacin 200mg bid iv 이후 임상증상 및 Lab 호전, urine and blood Cx: no growth. Peak BT normalization 10일간 관찰 후 discharge

16 Final diagnosis APN Lt with cystic infection Known ADPKD Acute on CRF
d/t infection and dehydration Type 2 DM Known HTN