x ray conference 2012.02.01
DESCRIPTION
報告者: fellow 1 陳筱惠. X ray conference 2012.02.01. Case 01. Patient Profile. Name: 陳 O 綢 Sex: female Age: 52-year-old Chart number: 21512475 Date of admission: 2012/01/07. Chief Complaint. Intermittent gross hematuria about half year. Present Illness. - PowerPoint PPT PresentationTRANSCRIPT
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報告者: fellow 1 陳筱惠
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Name: 陳 O 綢Sex: femaleAge: 52-year-oldChart number: 21512475Date of admission: 2012/01/07
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Intermittent gross hematuria about half year
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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
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Hypertension, diabetes mellitus, and chronic kidney disease (stage 5)
Urolithiasis: deniedOther significant systemic
diseases: deniedCurrent medicine: anti-HTN
medication and OHA from LMD
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Allergy: no known allergyAlcohol: denied; betel-nut: denied;
cigarette: deniedOver-the-counter medication or
chinese herb: nil
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No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases
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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
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WBC 6.2x1000/ul
Hgb 8.3 g/dl
Hct 24.5 %
MCV 90.7 fl
PLT 241 x1000/uL
Segment 59 %
Creatinine 5.11 mg/dl
GPT 19 IU/L
K 4.1 mEq/L
Sugar 162 mg/dl
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Color Dark yellow
Turbidity Cloudy
SP. Gravity 1.014
PH 6.0
Leukocyte 1+
Nitrite -
Protein 2+
Glucose Trace
Ketone -
Urobilinogen 0.1
Bilirulin -
Blood 3+
bacteria +
RBC >500/uL
WBC 63/uL
Epithelial cell 17/uL
01/04 urine culture: mixed flora
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T1
T2
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T1
T2
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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
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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.
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Origin Embryologically
Clinical Immunohistochemically
RCC
the parenchyma of the kidney, proximal convoluted tubules mesodermal
metanephros
• Clinical triad: <10% patient
• Paraneoplastic syndrome
Positive:vimentin, bcl-2, CD10, LMWCK, CK7Negative: CK8, CK19, CK20, HMWCK
TCC
urothelia of the renal pelvis and calices
• Hematuria: 75% patient
• Urine cytology: +
Positive:LMWCK, CK7, CK8, CK19, CK20, HMWCKNegative: vimentin, CD10
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Name: 徐 O 妹Sex: femaleAge: 71-year-oldChart number: 21511980 Date of admission: 2011/12/29
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Bilateral flank pain for several months
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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
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Underlying diseases: hypertensionOther significant systemic
diseases: deniedL‘t renal stone s/p PCWL and R‘t
ureteral stone with hydronephrosis s/p DJ
Current medicine: anti-HTN medication from LMD
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Allergy: no known allergyAlcohol: denied; betel-nut: denied;
cigarette: deniedOver-the-counter medication or
chinese herb: nil
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No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases
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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
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WBC 8.0x1000/ul
Hgb 10.9 g/dl
Hct 34.8 %
MCV 79.6 fl
PLT 283x1000/uL
Segment 73.4 %
BUN 70.4 mg/dl
Creatinine 10.23 mg/dl
GPT 9 IU/L
NA 138 mEq/L
K 5.3 mEq/L
Sugar 107 mg/dl
PH 7.247
PCO2 33.1 mmHg
PO2 65.9 mmHg
HCO3 14.1 mm/L
SaO2 90.1 %
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Color Yellow
Turbidity Turbid
SP. Gravity 1.007
PH 6.0
Leukocyte 3+
Nitrite +
Protein 1+
Glucose -
Ketone -
Urobilinogen 0.1
Bilirulin -
Blood 2+
bacteria +
RBC 5/uL
WBC 312/uL
Epithelial cell 1/uL
12/28 urine culture: E.coli
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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
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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
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2011/12/28 OP: bilateral DOUBLE-J URETERAL STENT INSERTION
2012/01/05 CT guided kidney biopsy: RENAL CELL CARCINOMA
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Name: 陳 O 慧Sex: femaleAge: 27-year-oldChart number: 20990430Date of admission: 2012/01/29
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Diffuse abdomninal dull pain with fever for 1 week
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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
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Ectopic pregnancy history post operation in 2006
Significant systemic diseases, like hypertension, diabetes mellitus: denied
Current medicine: nil
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Allergy: no known allergyAlcohol: social drainking; betel-nut:
denied; cigarette: 1ppd/day for 8 years
Over-the-counter medication or chinese herb: nil
Ketamine drug abuser??
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No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases
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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
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WBC 18.4x1000/ul
Hgb 6.4 g/dl
Hct 22.5 %
MCV 71.2 fl
PLT 600x1000/uL
Segment 88.5 %
Sugar 144 mg/dl
Creatinine 7.61 mg/dl
GPT 57 IU/L
Lipase 117 IU/L
ALK-P 984 IU/L
Bil (T) 0.4 mg/dl
NA 126 mEq/L
K 7.8 mEq/L
CRP 208.02 mg/L
PH 7.16
PCO2 22.6 mmHg
PO2 32.1 mmHg
HCO3 7.9 mm/L
SaO2 48 %
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Color Yellow
Turbidity Turbid
SP. Gravity 1.013
PH 8.0
Leukocyte 3+
Nitrite -
Protein 3+
Glucose -
Ketone -
Urobilinogen 0.1
Bilirulin -
Blood 3+
bacteria +
RBC 120/uL
WBC >500/uL
Epithelial cell 12/uL
01/28 urine culture: E.coli
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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.
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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
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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 abuseHistopathology 2011, 59, 579–593
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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
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