1. MGR Case Presentation
신장 내과

2. Admission Note Chief Complaint Fever with myalgia o/s 내원 2주전
송 O 석 (M/29) Adm via OPD
Chief Complaint
Fever with myalgia o/s 내원 2주전
Present Illness
평소 특이 병력 없는 29세 남자로 내원 2주전부터 열감과 근육통 있어 감기로 생각하고 지내다, 1주 전부터 피로감 심해지고, 입맛 이 없어 지는 증상 있어 근처 내과 내원하여 실시한 검사상 간수치 와 신장 수치 증가 소견 보여 정밀 검사 위해 내원. .

3. Admission Note Past medical history DM/HTN/TB/Hepatitis(-/-/-/-)
Op. history (-)‏
Drug history (+), herbal medication history (-)‏
Travel history (-), Food history (-), Allergy history (-)‏
Family history
No family history of kidney disease
No family history of liver disease
Personal history
Occupation : 창고 및 물류 관리직
Married male
Smoking(+)‏ : 10 pack-years
Alcohol(+) : 소주 1병/회, 주 1회

4. Review of System G/A fatigue (+) weight loss (+) 7-8kg
Febrile sensation (+)(-)
chilling (+)  (-)
sweating (-)
Skin
pigmentation(-)
itching sense(-)
H & N
headache (-)
neck stiffness (-)
Eye/ENT
visual disturbance (-)
diplopia (-)
hearing loss(-)
nasal obstruction (-)
rhinorrhea(-)
sore throat(-)
hoarseness(-)‏
Respiratory
cough (-)
sputum (-)
dyspnea(-)
pleuritic chest pain(-)
hemoptysis(-)‏
Cardiovascular
angina (-)
palpitation (-)
orthopnea(-)
dyspnea on exertion(-)‏ 4

5. Review of System G-I Anorexia(+) Nausea(-) Vomiting(-) Constipation(-)
Diarrhea(-)
Hematemesis(-)‏
Hematochezia(-)‏
Melena(-)
Abd .pain(+)  (-) : RUQ area, continuous
Renal &Urinary
dysuria(-)
hematuria(-)
urgency(-)
nocturia (-)
incontinence (-)
hesitancy(-)
oliguria(+) : 종이컵 한컵 분량 , 하루 3~4회
Musculoskeletal
myalgia (+)
numbness(-)‏
joint swelling(-)‏
joint pain (-) 5

6. Physical Examination
Vital sign) 110/70mmHg – 64/min – 18/min ’C
Height/Body weight : 170cm/76.9kg (BMI 26.6kg/m2)
General appearance
Alert mentality
Acute ill looking appearance
Skin
Rash (-) Pigmentation (-) Jaundice(+)‏ eschar (-)
Head and Neck
Normocephaly
LN enlargement(-/-)‏
Neck vein engorgement(-/-)‏
Thyroid enlargement(-)‏
Eyes and ENT
Isocoric pupil with PLR(++/++)‏
EOM : full
Pinkish conjunctiva, Icteric sclera
PTH/PI (-/-)‏

7. Physical Examination Chest Symmetric expansion
Clear breathing sounds without rale
Regular heart beats without murmur
Abdomen
Soft and Flat abdomen
Abdominal Tenderness/rebound tenderness(-/-)
Hepatomegaly(-)
Normoactive bowel sound
Back and extremities
CVA tenderness(-/-)‏
Pretibial pitting edema(-/-)‏

8. Initial lab findings CBC/DC (09/30 외부검사)
10770/mm² g/dl – 43.7% - 146K (seg : 38.1%, lympho : 44.8%)
aPTT sec PT(INR) (2.41)
CBC/DC (10/01 adm)
16330/mm² g/dl – 44.3% - 131K (seg : 27.1%, lympho : 40%)
aPTT sec PT(INR) (1.42)

9. Initial lab findings Chemistry (09/30 외부검사) TB 4.9 mg/dL BUN/Cr
49.1/6.5 mg/dL (eGFR 10.8 ml/min/1.73m2)
AST/ALT
3350/4802 U/L
Ca/P
7.8/5.3 mg/dL
ALP/r-GT
435/337 U/L LD
3340 mg/dL
Pro/alb
5.9/3.7 g/dL
Chemistry (10/01 adm)
TB/DB
5.89/4.96 mg/dL
BUN/Cr
57/8.9 mg/dL(eGFR 7.5 ml/min/1.73m2)
AST/ALT
2236/4171 U/L
Na/K/Cl
126/3.3/87 mmol/L
ALP/r-GT
138/347 U/L
Ca/P/Mg
7.8/3.2/2.7 mg/dL
Pro/alb
6.4/3.5 g/dL
Uric acid
16.5 mg/dL
LD/CK
1748/96 mg/dL
CRP
1.4 mg/dL
ABGA – 37.6 – 89.6 – 21.5 – 96.7%

10. Initial lab findings Urinalysis Occult blood +(10) Bilirubin +(0.5)
Urobilinogen
+-(0.1)
Protein
++(100) pH
5.0 SG
1.012
Urine microscopy
Micro RBC
10-29
Micro WBC
2-4
Spot urine
Protein/Cr
1670 mg/g Na
24 mmol/dL
(FeNa 1.57)
Urea
128 mg/dL
(FeBUN 46.59) 10

11. Initial lab findings EKG

12. Initial lab findings Chest PA12

13. Initial problem lists Fever Jaundice Oliguria 13
환자 입원당일 첫 소변 500ml, 24hrs 500ml 로 RIFLE criteria 에 따라 시간당 kg 당 0.3 ml 이하로 Acute kideney injury 에 있어 oliguria 소견에 합당하고, 혈중 creatinine 8.9 mg/dL로 cock-gault
Nonoliguria urine output >400ml/24hrs
Oliguria = 100~400ml/24hrs
Anuria , urineoutput <100ml/24hrs
Azotemina
A reduced GFR leads to retention of nitrogenous waste products (azotemia) such as urea and creatinine.
retention of nitrogenous waste products (azotemia) 13

14. Initial assessment #1. Acute hepatitis with ARF R/O Viral hepatitis
R/O Toxic hepatitis
R/O Autoimmune hepatitis
#2. Other infectious cause
R/O Leptospirosis
R/O Hantaan virus infection
R/O R. tsutsugamushi,
R/O R. typhi.
#3. Acute cholangitis with ARF
#4. R/O hepatorenal syndrome, underlying LC

15. Diagnostic plans #1. Acute hepatitis with ARF R/O Viral hepatitis
Abd.US, If needed, Abd.CT
Laboratory testings
R/O Viral hepatitis
Anti-HAV IgM, HBsAg and anti-HBc IgM, Anti-HCV
If needed, Anti CMV IgM, EBV viral markers
R/O Autoimmune hepatitis
IgG/A/M/E, SMA, ANA ,anti-LKM1 etc.
#2. Other infectious cause R/O Leptospirosis
R/O Hantaan virus infection
R/O R. tsutsugamushi. , R. typhi,.
Leptospiral Ab, Hantaan viral Ab, Rickettsial Ab
R/O Viral hepatitis
R/O Toxic hepatitis
R/O Autoimmune hepatitis

16. Diagnostic plans #3. Acute cholangitis with ARF
Fever study, inculding blood culture
Abd.US , if needed abd.CT
#4. R/O Hepatorenal syndrome, underlying LC
Alcohol history, medication history recheck
Abd.US
If needed, Abd CT
Viral marker for r/o chronic viral hepatitis

17. Abdominal US

18. Additional lab findings
Viral marker
anti-HAV IgM
Positive (15.14)
HBs Ag
Negative
anti-HBs Ab
Positive (51.32)
anti-HBc IgM
anti-HCV Ab

19. Additional lab findings
Immunologic marker
RPR
Negative
IgG
1460 mg/dL
IgA
226mg/dL
IgM
580 mg/dL
IgE
139 mg/dL
C-ANCA
P-ANCA
negative
ANA
Non reactive

20. Evaluaion of Azotemia Urinalysis (HD#1) Occult blood +(10) Bilirubin
+(0.5)
Urobilinogen
+-(0.1)
Protein
++(100) pH
5.0 SG
1.012
Urinalysis (HD#2)
Occult blood
+-(5)
Bilirubin -
Urobilinogen
+-(0.1)
Protein pH
5.5 SG
1.012
Urine microscopy
Micro RBC
10-29
Micro WBC
2-4
Urine microscopy
Micro RBC
0-1
Micro WBC 20

21. Evaluaion of Azotemia Spot urine HD #1 HD #2 Protein/Cr 1673 mg/gNa
(FeNa 1.57)
(FeNa 5.19)
Urea
(FeBUN 46.59)
BUN/Pcr Ratio
6.4:1
Urine sodium
24 meq/L
Urine osmolarity
168 mOsm/L
FeNa
1.57
Urine/plasma creatinine (Ucr/Pcr)
11.67

22. Evaluaion of Azotemia

23. Diagnosis Acute renal failure Acute tubular necrosis
--- associated with acute hepatitis A
Bile salt가 renal tubular cell에 uptake되며 이에 의한 renal tubular damage의 결과로 acute hepatitis와 함께 그 sequelae로 acute renal failure가 온 것으로 생각해 볼 수 있겠습니다.

24. Therapeutic Plan Acute hepatitis A
Hepatotonics
Symptomatic care
Nausea control, glucose supply
Acute renal failure d/t HAV infection
Urine output 유지 – diuretics 사용 , E’ F/U
If needed Hemodialysis, 24

25. Clinical course

26. Clinical course

27. Clinical course HD HD HD HD HD