Case Analysis

PGY1 劉上琪
Supervisor 歐世祥醫師
Case Report

ER course
 Case Profiles

Basic informations

• 鍾 OO ， 17664992
• 58y/o M
• bed ridden status, total ADL-dependent.
• Date of admission : 2020/03/30

Chief Complaint

general edema for 10 days with anuria developed for 2 days.

 Case Profiles

Underlying Disease / Past History

1. 1994 T4-T6 Spinal injury with paraplegia due to traffic accident
2. 1998 Ankylosing spondylitis, without treatment
3. 2019/12/05 obstructive uropathy, complicated with UTI.
4. Suspected bladder tumor, invasion to right UVJ

Personal History
• Smoking: 3PPD / day , for 20yrs, give up for 20+ years
• Alcohol: Denied
• Allergy history: Denied
• Family : older brother died of cancer.
• Occupation : driver
Review of Systems

General
• conscious
• cold sweating
Review of Systems
Skin
• skin rash over trunk, back and
four limbs

Digestive system
• poor appetite
• nausea
Review of Systems
Skin
• skin rash over trunk, back and
four limbs

Digestive system
• poor appetite
• nausea

Genitourinary system
• left flank pain
• no frequency, no urgency
 Review of Systems
Skin
• skin rash over trunk, back and
four limbs

dermatome : T6
Digestive system
• poor appetite
• nausea

Genitourinary system
• left flank pain
• no frequency, no urgency

Musculoskeletal system
• limbs and joint dysfunction due
to paraplegia.
• low back pain.
 Physical examinations
BP : 168/80mmHg T /P/R : 36.2 / 93 / 16 Sat: 99%

Consciousness alert
Skin skin turgor : normal
skin rash over trunk and limbs
HEENT supple, no JVE, no lymphadenopathy
Chest symmetrical expansion, clear BS
Heart regular heart beats w/o murmur
Abdomen soft without tenderness
no knocking tenderness
extremities pitting edema: +4
NE • Sensation level : T6
• MP : left upper/right upper : 4/4
Lab data at ER
BUN Crea. Na K eGFR
mg/dl mg/dl mmol/L mmol/L ml/min/
1.73
79 5.68 126 5.6 11

WBC Hgb MCV RDW PLT

K/ul g/fl fl % K/ul
10.8 11.6 83/2 15.1 285

SEG LYM MONO EOSINO BASO CRP

% % % % % mg/dl
79.1 5.5 5.3 9.8 0.3 6.89
pH pCO2 pO2 HCO3- ABEc SatO2
pH mmHg
pCO2 mmHg
pO2 mmol/L
HCO3- mmol/L
ABEc %
SatO2
7.276 22.5
mmHg 151.2
mmHg 10.2
mmol/L -14.77
mmol/L 98.8
%
Lab data at ER
BUN Crea. Na K eGFR
mg/dl mg/dl mmol/L mmol/L ml/min/
1.73
79 5.68
79 5.68 126 5.6
5.6 11
11
2019/12/09
BUN
WBC Crea.
Hgb MCV K
RDW eGFR
PLT
mg/dl
K/ul mg/dl
g/fl fl mmol/L
% ml/min/1.73
K/ul
7
10.8 0.63
11.6 83/2 3.6
15.1 139.5
285

SEG LYM MONO EOSINO BASO CRP

no baseline within 7 days, but acute anuria within 2 days
% % % % % mg/dl
79.1 5.5 5.3 9.8 0.3 6.89
Acute Kidney Injury
pH pCO2 pO2 HCO3- ABEc SatO2
mmHg mmHg mmol/L mmol/L %
Lab data at ER
BUN Crea. Na K eGFR
mg/dl mg/dl mmol/L mmol/L ml/min/
1.73
79 5.68 126 5.6 11

WBC Hgb MCV RDW PLT

K/ul g/fl fl % K/ul
10.8 11.6 83/2 15.1 285

SEG Metabolic
LYM MONO Acidosis
EOSINO BASO CRP
% % % % % mg/dl
79.1 5.5 5.3 9.8 0.3 6.89
pH pCO2 pO2 HCO3- ABEc SatO2
pH mmHg
pCO2 mmHg
pO2 mmol/L
HCO3- mmol/L
ABEc %
SatO2
7.276
7.229 22.5
39.5
mmHg 151.2
20.7
mmHg 10.2
16.1
mmol/L -14.77
-10.74
mmol/L 98.8
22.5
%
 Lab data at ER Urine Analysis

SPG. PH PRO. SUG. KET. O.B. URO. BIL. NIT. LEU

.
mg/dl mg/dl mg/dl mg/dl mg/dl
1.028 8 >=500 150 5 - normal - - -

RBC WBC EPITH. Others

PUS CELL
/HP /HP /HP /HP
10.8 20-29 6-9 bacteria: +2
 Lab data at ER Urine Analysis

SPG. PH PRO. SUG. KET. O.B. URO. BIL. NIT. LEU

mg/dl mg/dl mg/dl .
mg/dl
>=500 mg/dl
150 mg/dl
5 mg/dl mg/dl
1.028 8 >=500 150 5 - normal - -- --

RBC WBC Others

RBC PUS
WBC EPITH. Others
/HP /HP
PUS CELL /HP
10.8
/HP 20-29
/HP /HP bacteria: +2
/HP
10.8 20-29 6-9 bacteria: +2

r/o UTI
Image
2020/03/30
Image
Image
2019/12/15
Image
2020/03/30
Image
2020/03/31

• LK: 11.49 cm.

• mild left hydronephrosis
• renal stone, 0.82 cm. Left renal cysts.
Image
2020/03/31
Image
2020/03/31
Image
2020/03/31

• RK: 9.03 cm
• Moderate to severe right hydronephrosis and
hydroureter
• Increased echogenicity of renal parenchyma
Image
2020/03/31
Image
2020/03/31
Image
2020/03/31

• Prostate : 19.43 cc
• heterogenecity.
Past Image
2019/11/29
Past Image
2019/11/29
Past Image
2019/11/29
Past Image
2019/11/29
Past Image
2019/11/29
Past Image
2019/11/29
Past Image
2019/11/29
Management at ER

3/30 on Foley
Hydration with N/S 1000cc
UOP : still 30cc a day

3/31 Admission
Problem List

• Edema
• Anuria / Acute kidney Injury
• Metabolic acidosis
• Bladder Tumor
 Discussion

Edema
Anuria / Acute kidney Injury
Metabolic acidosis
Bladder Tumor
 Approach to Edema

Location Bilateral or Unilateral

• Pitting or non-pitting
Quality • Pain or no pain
Quantity Grading ： 4+

Onset Acute or Chronic

Predisposing Medication, intake (Neg)

Exacerbating Fluid/salt intake (Neg)

Relieving Relieved by sleep or not ?

HF, cirrhosis, nephrotic syndrome or CKD,
Associated hypothyroidism, DVT
 Approach to Edema

- DVT
- Pelvic tumor /LN dissection
Localized - FVC
- Cellulitis ( inflammatory edema)
- CVA with hemiplegia or hemiparesis

Edema
Congestive heart failure

Liver disease
Generalized
Nephrogenic edema

Miscellaneous
 Approach to Edema

- DVT
- Pelvic tumor /LN dissection
Localized - FVC
- Cellulitis ( inflammatory edema)
- CVA with hemiplegia or hemiparesis

Edema
Congestive heart failure

Liver disease
Generalized
Nephrogenic edema

Miscellaneous
 Approach to Edema

- DVT
- Pelvic tumor /LN dissection
Localized - FVC
- Cellulitis ( inflammatory edema)
- CVA with hemiplegia or hemiparesis

Edema
Congestive heart failure

Liver disease
Generalized
Nephrogenic edema

Miscellaneous
Congestive DOE, orthopnea, PND, • normal hemogram,
heart failure JVD, cardiomegaly • n/↑azotemia
• proteinuria(-)
Liver Orthopnea(-), PND(-) • ↓ Hb
disease Stigmata of L/C • ↓ plt
• abnormal LFTs
Nephrogenic • DOE, orthopnea, PND, JVD,
edema Renal failure cardiomegaly
• Anemia
• Azotemia, variable proteinuria
• Dyspnea
• May have massive pleural
Nephrotic syndrome
effusion
• Usually absence of azotemia
• Heavy proteinuria (> 3.5 g/d)
Miscellaneous • Malnutrition • Using NSAID, CCB
• Protein-losing enteropathy
• Myxedema
• Idiopathic cyclic edema
• Filariasis, Drug associated
Congestive DOE, orthopnea, PND, • normal hemogram,
heart failure JVD, cardiomegaly • n/↑azotemia
• proteinuria(-)
Liver Orthopnea(-), PND(-) • ↓ Hb
disease Stigmata of L/C • ↓ plt
• abnormal LFTs
Nephrogenic • DOE, orthopnea, PND, JVD,
edema Renal failure cardiomegaly
• Anemia
• Azotemia, variable proteinuria
• Dyspnea
• May have massive pleural
Nephrotic syndrome
effusion
• Usually absence of azotemia
• Heavy proteinuria (> 3.5 g/d)
Miscellaneous • Malnutrition • Using NSAID, CCB
• Protein-losing enteropathy
• Myxedema
• Idiopathic cyclic edema
• Filariasis, Drug associated
Congestive DOE, orthopnea, PND, • normal hemogram,
heart failure JVD, cardiomegaly • n/↑azotemia
• proteinuria(-)
Liver Orthopnea(-), PND(-) • ↓ Hb
disease Stigmata of L/C • ↓ plt
• abnormal LFTs
Nephrogenic • BUN:79mg/dl
DOE, orthopnea, PND, JVD,
edema Renal failure crea:5.98mg/dl
cardiomegaly
• Anemia
• Azotemia, variable proteinuria
• Dyspnea
• May have massive pleural
Nephrotic syndrome
effusion
• Usually absence of azotemia
• Heavy proteinuria (> 3.5 g/d)
Miscellaneous • Malnutrition • Using NSAID, CCB
• Protein-losing enteropathy
• Myxedema
• Idiopathic cyclic edema
• Filariasis, Drug associated
Congestive DOE, orthopnea, PND, • normal hemogram,
heart failure JVD, cardiomegaly • n/↑azotemia
• proteinuria(-)
Liver Orthopnea(-), PND(-) • ↓ Hb
disease Stigmata of L/C • ↓ plt
• abnormal LFTs
Nephrogenic • BUN:79mg/dl
DOE, orthopnea, PND, JVD,
edema Renal failure crea:5.98mg/dl
cardiomegaly
• Anemia
• Azotemia, variable proteinuria
• Dyspnea
• May have massive pleural
Nephrotic syndrome
effusion
2020/04/01 Alb : 2.6 mg/dl
• Usually absence of azotemia
• Heavy proteinuria (> 3.5 g/d)
Miscellaneous • Malnutrition • Using NSAID, CCB
• Protein-losing enteropathy
• Myxedema
• Idiopathic cyclic edema
• Filariasis, Drug associated
Congestive DOE, orthopnea, PND, • normal hemogram,
heart failure JVD, cardiomegaly • n/↑azotemia
• proteinuria(-)
Liver Orthopnea(-), PND(-) • ↓ Hb
disease Stigmata of L/C • ↓ plt
• abnormal LFTs
Nephrogenic • BUN:79mg/dl
DOE, orthopnea, PND, JVD,
edema Renal failure crea:5.98mg/dl
cardiomegaly
• Anemia
• Azotemia, variable proteinuria
• Dyspnea
• May have massive pleural
Nephrotic syndrome
effusion
• Usually absence of azotemia
• Heavy proteinuria (> 3.5 g/d)
Miscellaneous • Malnutrition • Using NSAID, CCB
no sign of hypothyroidism
• Protein-losing enteropathy
• Myxedema
• Idiopathic cyclic edema
• Filariasis, Drug associated
 Liver Nephrotic Renal
Heart failure
disease syndrome Failure
Anemia - + - +

Azotemia - - - +

Proteinuria - - +++ +~++

Distended + - - +
jugular vein
 Discussion

Edema
Anuria / Acute kidney Injury
Metabolic acidosis
Bladder Tumor
Acute V.S. Chronic Kidney Disease
Acute V.S. Chronic Kidney Disease

acute decrease of UOP ( in 2 days)

Acute V.S. Chronic Kidney Disease
Acute V.S. Chronic Kidney Disease

• LK : 11.49 cm
• RK : 9.03 cm
Acute V.S. Chronic Kidney Disease
Acute V.S. Chronic Kidney Disease
 Acute V.S. Chronic Kidney Disease

Acute on chronic could not be ruled out

 Acute Kidney Injury
Definition : KDIGO criteria

Diagnostic ↑SCrea ≥0.3 mg/dL in 48hrs UOP < 0.5 mL/kg/hour > 6 hrs

OR
≥50% in 7 days
Stage 1 △Crea ≥0.3 mg/dL or UOP <0.5 mL/kg/hr , 6-12 hrs
1.5-1.9 times baseline

Stage 2 △Screa 2-2.9 times baseline UOP of <0.5 mL/kg/hr , 12-24

hrs

Stage 3 △SCrea to ≥3 times baseline UOP of <0.3 mL/kg/hr, ≥24 hrs

OR or anuria ≥12 hrs
△SCrea of ≥0.3 → ≥4.0
mg/dL¶
OR
Initiation of dialysis
 Acute Kidney Injury
Definition : KDIGO criteria

Diagnostic ↑SCrea ≥0.3 mg/dL in 48hrs UOP < 0.5 mL/kg/hour > 6 hrs

OR
≥50% in 7 days
Stage 1 △Crea ≥0.3 mg/dL or UOP <0.5 mL/kg/hr , 6-12 hrs
1.5-1.9 times baseline

Stage 2 △Screa 2-2.9 times baseline UOP of <0.5 mL/kg/hr , 12-24

hrs

Stage 3 △SCrea to ≥3 times baseline UOP of <0.3 mL/kg/hr, ≥24 hrs

OR or anuria ≥12 hrs
△SCrea of ≥0.3 → ≥4.0
mg/dL¶
OR
Initiation of dialysis
Acute Kidney Injury
Etiology
 Discussion

Edema
Anuria / Acute kidney Injury
Metabolic acidosis
Bladder Tumor
2020/04/01
pH pCO2 pO2 HCO3- ABEc SatO2
mmHg mmHg mmol/L mmol/L %
7.276 22.5 151.2 10.2 -14.77 98.8
Na Cl UNa UK UCl
mmol/L mmol/L mmol mmol/L mmol/L
126 101 89 9.4 89

代償計算
↓PaCO2 = ↓HCO3 x 1.25 = (24-10.2) X 1.25 = 17.25
40-17.25 = 22.75  代償適中

AG 計算
AG : Na – Cl – HCO3 = 14.8
expected AG : [alb] x 2.5 = 6.5  high AG
14.8 – 6.5 = 8.3
△△=△AG / △HCO3 = <1
24 – 10.2 = 13.8
 AG met. acid. + non-AG met. acid.
v 2020/03/30
U ketone S glu.
mg/dl mg/dl
5 97
2020/04/02 serum
lactate ketone sugar
no drug history
mmol/L mmol/L mg/dl
no alcohol intake
0.62 1.7 109
 About fasting ketoacidosis
Fasting Ketosis

• Mild ketosis ( 1mmol/L) : develops after a 12-14 hour fast.

• if fast continue :
• peak at 20 to 30 days, S[ketone] : 8~10 mmol/L
• S[HCO3] : ↓7-8 mEq/L (18 mEq/L)

Fasting Ketoacidosis

• accumulation of B-hydroxybutyric + acetoacetic acid

• usually occur in very young (neonates) or pregnant women

Our patient : glu:97mg/dl, ketone:1.7mmol / L , HCO3: 10.2mmol/L

combine with other etiology of met. acidosis

2020/04/01
pH pCO2 pO2 HCO3- ABEc SatO2
mmHg mmHg mmol/L mmol/L %
7.276 22.5 151.2 10.2 -14.77 98.8
Na Cl UNa UK UCl UpH
mmol/L mmol/L mmol mmol/L mmol/L
126 101 89 9.4 89 8

UAG 計算
UNa + UK – UCl = 89 + 9.4 – 89 = 9.4 > 0
Urine pH : 8
AG metabolic acidosis + non-AG metabolic acidosis

fasting ketoacidosis early renal failure

 Discussion

Edema
Anuria / Acute kidney Injury
Metabolic acidosis
Bladder Tumor
 Approach to bladder tumor
Symptoms & signs

• gross or microscopic hematuria

• obstructive voiding symptoms

Risk factors

• 抽菸
• 重金屬：服用含有馬兜鈴酸的中藥材、頻繁染髮、砷
• 血液透析患者
• 服用抗排斥或免疫抑制劑
 Approach to bladder tumor
Diagnosis

• cystoscope is gold standard : detect lesion location

• urine cytology 2019/12/08 – 12/12 : 6 sets of urine cytology : negative

• contrast CT/MRI : for staging, evaluation of muscle-invasion

• Transurethral resection of bladder tumor (TURBT) : to assess

histologic grade and depth of invasion

Discussion

Brief Summary
Brief Summary

Bladder Tumor Chronic hematuria , image

Urinary Tract Obstruction

Hydronephrosis UTI
post-renal AKI Edema
Anuria
acute proteinuria

Non-AG Metabolic acidosis

AG Metabolic acidosis Starvation
Case Report

Back to our case……

 Hospital Course

3/30 on Foley, UOP : still 30cc a day

3/31 Admission
Right PCN insertion, UOP : 230cc
UTI : Ceftriaxone on 3/31~4/3

4/01 Left PCN insertion, UOP : 3750cc.

3 sets of urine cytology : 1 set -> atypical cells

4/06 metabolic acidosis, BUN, creatinine improved.

4/08 antegrade pyelography : bil. 3/L obstruction.

4/09 follow up renal function and arrange CT.

 Hospital Course

• early renal failure corrected Evidence of AKI

• normal diet + recovery of renal function

 Metabolic acidosis corrected
 Hospital Course

3/30 on Foley, UOP : still 30cc a day

3/31 Admission
Right PCN insertion, UOP : 230cc
UTI : Ceftriaxone on 3/31~4/3

4/01 Left PCN insertion, UOP : 3750cc.

3 sets of urine cytology : 1 set -> atypical cells

4/06 gas, BUN, crea all improved.

4/08 antegrade pyelography : bil. 3/L obstruction.

2020/04/08
 Hospital Course

3/30 on Foley, UOP : still 30cc a day

3/31 Admission
Right PCN insertion, UOP : 230cc
UTI : Ceftriaxone on 3/31~4/3

4/01 Left PCN insertion, UOP : 3750cc.

3 sets of urine cytology : 1 set -> atypical cells

4/06 gas, BUN, crea all improved.

4/08 antegrade pyelography : bil. 3/L obstruction.

4/09 abdomen CT.

2020/04/09

2019/11/29