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X-ray Conference

X-ray Conference. Presented by F1 林立原 Commented by Dr. 王俐人 2011/07/13. Case 1: 20698462 Case 2 : 21500213. Case 1: 20698462. General Data. Age: 44-year-old Gender: female Ethnic: Taiwanese Marital status: Married Occupation: 工人 Admission date: 2011/06/30. Chief Complaint.

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X-ray Conference

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  1. X-ray Conference Presented by F1 林立原 Commented by Dr.王俐人 2011/07/13

  2. Case 1: 20698462Case 2: 21500213

  3. Case 1: 20698462

  4. General Data • Age: 44-year-old • Gender: female • Ethnic: Taiwanese • Marital status: Married • Occupation: 工人 • Admission date: 2011/06/30

  5. Chief Complaint • Right flank pain for 1 day

  6. Present Illness • This 44-year-old female has unremarkable medical history before. • She presents to the Urology OPD because of right flank pain for 1 day, along with fever episodes. At the beginning, she visited St. Paul hospital, where kidney echogram disclosed a right renal mass measuring 7cm in diameter. • She denies gross hematuria, urinary frequency, urgency, dysuria, body weight loss, or abdominal pain.

  7. Past History • Severe left hand crushing injury by the machinery at work in Feb, 2004, post complete amputation flap.

  8. Personal History • No known allergy to food or drugs • Denies smoking, alcoholism, or betel nuts chewing.

  9. Physical Examination • BT 38.1℃ PR: 115/min, RR: 18/min, BP: 115/91mmHg • Consciousness: alert and oriented • HEENT: pink conjunctiva, anicteric sclera • Chest: smooth respiration, bilateral clear breathing sounds. • Heart: regular heart beats, no murmurs. • Abdomen: soft and flat, normoactive bowel sounds • Knocking pain: negative • Extremity: freely movable, no pitting edema.

  10. Laboratory Findings

  11. Laboratory Findings

  12. Laboratory Findings

  13. KUB

  14. 2011/06/29 Kidney Echo

  15. 2011/06/29 Kidney Echo • Left Kidney Length: 10.5 cm • Right Kidney Length: 12.0 cm • There is mild pelvocalycealdilatation over right central sinus area. • There is a mixed echoic lesion (8.1*6.0 cm) without acoustic shadow protruding from the middle portion of right kidney.

  16. 2011/6/29 Abdominal CT

  17. 2010/6/29 Abdominal CT

  18. 2010/6/29 Abdominal CT

  19. 2010/6/29 Abdominal CT • Right renal mass (6.8 x 5.2 cm) at upper pole presented with multiloculatedcysts and internal septatations. The renal tumor extended into the right renal pelvis region, causing dilatation of right renal calyx. The cystic component is fluid density. No obvious locoregional lymphadenopathies. • Multiloculatedcystic nephromawas considered. DDx: cystic RCC, renal abscess.

  20. Urine cytology • Negative for malignancy

  21. Diagnosis • 1. Right renal cystic mass, rule out renal cell carcinoma • 2. Right acute pyelonephritis

  22. Discussion • What is the nature of the renal mass?

  23. Solid renal masses • Renal cell carcinoma • Oncocytoma: central scar, homogenous • Angiomyolipoma: fat tissue • Metanephric adenoma: rare disease

  24. Solid renal masses • Imaging studies cannot reliably distinguish benign solid lesions from renal cell carcinoma (RCC). Surgical resection is generally indicated.

  25. Case 2: 21500213

  26. General Data • Age: 51-year-old • Gender: male • Ethnic: Hakka • Marital status: married • Occupation: truck driver

  27. Chief Complaint • Sudden onset of fever with chills for 1 day

  28. Present Illness • This 51-year-old male has unremarkable medical diseases. He presented to the ED with sudden onset of fever with chills for 1 day, associated symptoms including poor appetite and abdomen fullness for one week, micturition burning sensation and left side flank pain for 2 days.

  29. Present illness • He denies difficult urination, urinary frequency, urgency or turbid urine. • He visited Far Eastern Memorial hospital initially, urinary tract infection with bacteremia(B/C: GNB) was impressed; by his family’s request, he was transferred to CGMH.

  30. Past History • Left hydrocele known for one year, without any treatment • Meningitis history 20 years ago

  31. Personal History • No known allergy • Smoking: 2 pack per day for more than 30 years • Alcohol consumption:高梁酒0.5 bottle/day, beer 3 bottle/day more than 30 years • Betel nut chewing: occasional

  32. Physical Examination • BT 38.1℃ PR: 107/min, RR: 20/min, BP: 157/77mmHg • General appearance: fair • Consciousness: alertand oriented • HEENT: pink conjunctiva, anicteric sclera • Chest: symmetrical chest expansion, bilateral clear breathing sounds. • Heart: regular heart beats • Abdomen: soft, normoactive bowel sounds • CV angle knocking pain over left side • Extremity: freely movable, no pitting edema • Left hydrocele about 10*5 cm, no tenderness

  33. Laboratory Findings

  34. Laboratory Findings

  35. Laboratory Findings Blood and urine culture: E. coli

  36. 2011/07/04 Kidney echo

  37. 2011/07/04 Kidney Echo • Left kidney length: 11.4cm • Right kidney length: 11.8 cm • The cortical echogenicity is increased with increased thickness in right kidney . The right pelvocalycealsystem is mild dilated. There is acoustic shadow like pattern in the upper-middle area of left kidney suspecting emphysematous change.

  38. 2011/07/04 Abdominal CT

  39. 2011/07/04 Chest CT (C+/-) • Present feacture of emphysematous pyelonephritis on Lt, and nephritis on Rt • Feactureof urinary bladder with air bubbles. • Enlarged LNs along aorta probably reaction. • Hydrocele, L’tgroin. • Splenomegaly • Impressions: Emphysematous pyelonephritis on Lt, and acute nephritis on Rt

  40. 2011/07/06 Surgical intervention • Drainage of perirenal abscess • OP Finding: two PCN was inserted into the reproperitoneal space to drain the emphyselomatous pyelonephritis • No active bleeding

  41. Diagnosis • Left emphysematous pyelonephritis • E. coli bacteremia, due to pyelonephritis • Newly diagnosed diabetes mellitus • Hyponatremia and hypokalemia

  42. Discussion • Brief review of emphysematous pyelonephritis

  43. Emphysematous pyelonephritis • Mean age: 60 y/o (37-83 y/o) • Male : Female= 1: 6 • Major risks: diabetes mellitus, urinary tract obstruction • The main causes of urinary tract obstruction were papillary necrosis rather than ureteral calculi • Usually caused by Escherichia coli(69%) or Klebsiellapneumoniae(29%) Arch Intern Med 2000; 160:797.

  44. Emphysematous pyelonephritis • Diagnostic instruments: plain films, ultrasound, CT scan. CT scan is the most sensitive • Treatment: nephrectomy or open drainage along with systemic antibiotics

  45. Emphysematous pyelonephritis Arch Intern Med 2000; 160:797.

  46. Emphysematous pyelonephritis • Risk factors of mortality: • 1. Bilateral involvement • 2. On imaging, renal parenchymal necrosis with either no fluid content or a streaky/mottled gas pattern • 3. Conservative therapy without PCD • 4. Thrombocytopenia J Urol 2007; 178:880.

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