6월 16일 학생 case 발표

<DIV class=O v:shape="_x0000_s1026">상부요로감염과 sepsis정의가 중요함 (m/c 균 E.coli), </DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">SIRS <BR>다음의 4가지 중 최소한 두 개를 만족 <BR>(1)oral temperature of >38℃ or <36℃ (2)respiratory rate of >20 회/min or PaCO₂of 32torr (3) heart rate of >90 beats/min (4) leukocyte count of >12000/ul or <4000/ul or >10% bands <BR></DIV> <DIV class=O v:shape="_x0000_s1026">Sepsis <BR>감염에 의한 것으로 추정되거나 증명된 SIRS <BR></DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">F/46<BR>       Fever/Chills  <BR>       Lt. flank pain    o/s)3일전<BR>                                                     <BR>       General weakness    o/s)내원당일</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">F/46, 10년 전 Intrauterine device 시술 받고 별다른 이상없이 건강히 지내던 자로 한달 전 type2 DM 진단 받고 OHA복용하던 자임.<BR>    <BR>   내원 3일전 갑자기 발생한 fever, chill, flank pain Lt., vomiting diarrhea(수십차례) 발생해 local 입원 하여 치료 받았으나 증상 호전 없었고, 다음 날 혈압 저하되어 (80/50) Normal saline hydration 5L 후 혈압은 상승(130/80)하였으나  Oliguria 발생하고 LFT 이상소견 보여 본원 전원.<BR>   (local 에서 항생제 ciprofloxacin 사용함)<BR></DIV> <DIV class=O v:shape="_x0000_s1026">DM control 잘 안되던 환자에서 발생한 UTI  이며 sepsis로 진행한 양상의 환자입니다.</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">problem list</DIV> <DIV class=O v:shape="_x0000_s1026">#1.  Fever / chill <BR>#2.  CVA tenderness, Lt. <BR>#3.  Upper abdominal pain & tenderness <BR>       (epigastiric & RUQ)<BR>#4.  십여회의 vomiting, diarrhea<BR>#5.  Dehydrated tongue<BR>#6.  Oliguria<BR>#7.  H/o Shock  s/p> hydration (5L)<BR>#8.  Dyspnea, Tachypnea, Orthopnea<BR>#9.  Liver enzyme 상승 (Local lab)<BR>#10.Known type 2 DM<BR>#11.Intrauterine device insertion state<BR></DIV> <DIV class=O v:shape="_x0000_s1026">Assessment</DIV> <DIV class=O v:shape="_x0000_s1026">#1-7. Shock d/t Sepsis d/t Urinary tract infection<BR>                                            GI tract infection                                                 <BR>                                            Biliary tract infection <BR>                           Hypovolemia d/t dehydration                                                        <BR>                                          (fever, vomiting, diarrhea) </DIV> <DIV class=O v:shape="_x0000_s1026">#1-7, 8. Pulmonary congestion d/t vol. overload<BR>                                                         R/o septic shock<BR>                                                         R/o CHF <BR>#1-8, 9. LFT elevation d/t congestive hepatopathy<BR>                                           Liver or Biliary infection<BR>#10.  Known type 2 DM</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">DIC에 빠질 가능성 고려해 lab 나가야 합니다.</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">-DIC lab- <BR>    PT 15.1(66%)  INR 1.32   aPTT 48 <BR>    D-dimer >2.0   FDP >20</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">anemia 있어 anemia w/u 했습니다. </DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">MCV/MCHC 77.9/35.3  Fe 79 TIBC 238  Ferritin  >2000   <BR>        PB Morphology  normocytic normochromic</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">Disease Review</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">Complicated UTI란??</DIV> <DIV class=O v:shape="_x0000_s1026">요로계의 구조적/기능적 장애, 기저질환, 시술 등에 합병되어 발생한 UTI </DIV> <DIV class=O v:shape="_x0000_s1026"> Catheter insertion ,voiding mechanism의 국소적이나 기능적 이상, 당뇨 , 결석에 의한 obstruction, ADPKD, 신이식, 면역저하 등의 상황</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">당뇨환자의 Complicated UTI </DIV> <DIV class=O v:shape="_x0000_s1026">Emphysematous pyelonephritis/cystitis<BR>Papillary necrosis<BR>Perirenal abscess<BR>Urosepsis<BR><BR>Emphysematous pyelonephritis/cystitis</DIV> <DIV class=O v:shape="_x0000_s1026">원인균 : E.coli(m/c 84%), Klebsiella, proteus</DIV> <DIV class=O v:shape="_x0000_s1026">증상  : high fever, leukocytosis, renal parenchymal necrosis, kidney와 perinephric tissue에 gas 축적<BR>진단 : KUB, IVP, CT<BR>치료 : 침범된 조직의 수술적 절제 + 항균</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">Papillary necrosis</DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">증상<BR> hematuria, pain in flank or abdomen, chills,<BR> acute renal failure<BR></DIV> <DIV class=O v:shape="_x0000_s1026">진단<BR>  Necrotic tissue in urine<BR>  Ring shadow in pyelogram<BR>  DM 이나 chronic UTI환자에서 신기능이 급격히 감소되면 의심</DIV> <DIV class=O v:shape="_x0000_s1026"><BR>치료 일측성은 신절제, 양측성은 보존적 치료 </DIV> <DIV class=O v:shape="_x0000_s1026"> </DIV> <DIV class=O v:shape="_x0000_s1026">Urosepsis</DIV> <DIV class=O v:shape="_x0000_s1026">정의 : Sepsis resulting from the decomposition of extravasated urine<BR>Predisposing factor : 당뇨, Immune suppression state, catheter insertion, complicated UTI, 부적절한 항생제 사용                                                   <BR>치료  : 가능한 항생제를 빨리 시작  should be given intravenously. <BR> </DIV>