# 3/19 report
王惠仁 (90M)
17408876
--請準備PPT(口頭報告約10分鐘即可)+完成3份會議紀錄

出院診斷：
[Active illness]
1. Pneumonia with septic shock, blood culture: Candida glabrata
status post Ceftazidime (2021/02/13-02/15), Tazocin (2021/02/15-02/22), under sultamicillin (2021/02/22-2/
24)
s/p Tazocin (2021/2/24~3/1)
s/p Meropenem(3/1~, Cravit(2/26, 3/1~), and Micafungin (2021/3/1~)

2. Acute respiratory failure, related to aspiration pneumonia and pulmonary edema
3. End-stage renal disease with pulmonary edema
4. Type 2 diabetes mellitus with diabetic nephropathy, polyneuropathy, and retinopathy
5. Normocytic anemia, suspected gastrointestinal bleeding and renal anemia,
status post PRBC 1U transfusion on 2021/02/08-02/09, 02/11-02/12, 02/17, 02/22-02/23
under Darbepoetin 20mcg weekly since 2021/02/18
6. Bleeding of oral mucosa and tongue, suspected uremic bleeding
7. Gross hematuria

[Chronic illness]
1. Hypertensive cardiovascular disease
2. Rapidly progressive dementia, etiology to be determined
* Brain MRI failed due to agitation and patient's son refused sedation
* Patient's son refused lumbar puncture
3. Urothelial carcinoma high grade, without further diagnosis or treatment due to the patient and family's re
fusal
4. Hypothyroidism, under eltroxin supplement
5. Calcified aortic valve with moderate to severe aortic stenosis
6. Benigh prostatic hyperpalsia
7. Old pulmonary tuberculosis, status post anti-tuberculosis treatment

主訴：
Decreased urine output and oral intake observed by his son for two weeks

病史：
This is a 90-year-old ADL totally-dependent, nearly bedridden male patient has a history of (1) chronic ki
dney disease, stage 5, with renal anemia, (2) type 2 diabetes mellitus with diabetic nephropathy, polyneuropat
hy, and retinopathy, (3) hypertension, (4) rapidly progressive dementia, etiology to be determined, without de
finite diagnosis due to failure of previous examination and family's refusal of further invasive examination,
(5) high-grade urothelial carcinoma , without further diagnosis or treatment due to the patient and family's
refusal, (6) hypothyroidism, under eltroxin supplement, (7) calcified aortic valve with moderate to severe ao
rtic stenosis, (8) benigh prostatic hyperpalsia, and (9) old pulmonary tuberculosis, status post anti-tubercul
osis treatment.

According to the statement of his son, the patient had maintained daily urine output about 500 to 600 mL a
t home until the mid January, 2021. Decreased urine output and oral intake have been observed in recent two we
eks. He did not have fever, chills, shortness of breath, coffee-grounds vomitus, hemoptysis, vomiting, chest p
ain, abdominal pain, dysuria, tarry or bloody stool. He did not have recent traveling or contact history other
than his visits at our outpatient deparment. He was brought back to our renal clinic follow-up, where physica
l examination revealed anemic conjunctivae and dry skin turgor. Laboratory data disclosed normocytic anemia (H
b: 6.6 g/dL, MCV: 97.5 fl), hypoalbuminemia (3.2 g/dL), progressive azotemia (BUN 125 mg/dL, creatinine 14.61
mg/dL), and hyponatremia (133 mmol/L). Under the impression of acute kidney injury on chronic kidney disease,
the patient was admitted for further evaluation and treatment.

特殊病史：
過去病史：
[Chronic illness]
1. Chronic kidney disease, stage V, with renal anemia
2. Type 2 diabetes mellitus with diabetic nephropathy, polyneuropathy, and retinopathy
3. Hypertension
4. Rapidly progressive dementia, etiology to be determined
* Brain MRI failed due to agitation and patient's son refused sedation
* Patient's son refused lumbar puncture
5. Urothelial carcinoma high grade, without further diagnosis or treatment due to the patient and family's re
fusal
6. Hypothyroidism, under eltroxin supplement
7. Calcified aortic valve with moderate to severe aortic stenosis
8. Benigh prostatic hyperpalsia
9. Old pulmonary tuberculosis, status post anti-tuberculosis treatment

個人習慣及過敏史：
Smoking: denied
Alcohol: denied
Betel nut: denied
Travel history: denied
Allergy history: Contrast medium with anaphylactic shock.

家族病史：
Patient denied known hereditary disease or family history of medical diseases, including hypertension, diabete
s mellitus or renal disease as well as the following medical diseases for the children, parents and siblings)
including
1. Family history of cardio-vascular disease: nil
2. Family history of malignant disease: nil
3. Family history of psychiatric disease: nil
4. Family history of pulmonary disease: nil
5. Family history of congenital disease: nil
6. Family history of endocrine/obese disease: nil

住院治療經過：
After admission, PRBC 1U was transfused. Gentle hydration with D5S 250 mL per day were prescribed. On 2021/02/
09, PRBC 1U was transfused. Transient conscious disturbance was noted on 2021/02/11, and nasogastic tube was i
nserted with tube feeding. For anemia (Hb 6.2 gm/dL), PRBC 1U was transfused on 2021/02/11 and 2021/02/12. On
2021/02/13 early morning, a fever episode occurred. Some sputum was noted. Chest X-ray revealed increased inf
iltration over both lung regions. After septic work-up, empiric antibiotics with ceftazidime was prescribed. O
ral mucosal oozing due to previous tongue bite was noted, and oral paste was applied.

On 2021/02/15, antibiotics was shifted to Tazocin. The patient's consciousness level gradually improved to his
baseline status. Gentle hydration was discontinued after oral intake improved. The oral bleeding gradually su
bsided and the wounds were clotted and healing. On 2021/02/17, PRBC 1U was transfused. On 2021/02/18, platelet
apheresis 1U was transfused. We consulted dietitian for and adjusted diet replacement (腎補納) into 3.5 bot
tle per day. Sputum specimen was obtained again but still poor quality even under suction method. Darbepoetin
20mcg was administered weekly since 2021/02/18. On 2021/02/22, bleeding in right side buccal mucosa was noted
. PRBC 1U was transfused. Follow-up laboratory data showed CRP level within normal limits. Tazocin was shifted
to oral sultamicillin. Hospice team was consulted to assist the arrangement of home-based medical care. On 20
21/02/23, PRBC 1U was transfused. Oral mucosa bleeding improved. Foley was removed on 2/28 due to urine extrav
asation despite repeated balloon inflation and discussion with family. Gross hematuria with blood clots develo
ped on 2/28. U/R showed hematuria. Lab showed
anemia and thrombocytopenia. A three-way Foley with normal saline irrigation was started. He received 2u of pR
BC with 1u of PLT pheresis.

On 3/01, around 15:00, patient developed dyspnea and tachycardia. His consciousness was E4V2M5, as his usual p
erformance. PE showed no obvious rales at bilateral lung field. Lab data showed profound azotemia but lactate
acidosis, hypoxia, and elevated values of CRP and PCT. Nonrebreathing mask was used and it could keep periphe
ral saturation around 98-99%. Hydrocortisone and Atrovent were used for obvious wheezing after vomitting occur
red. We kept NG free drainage, sputum and food material suction, and lying on his right side for prevention of
aspiration. Chest X ray showed increased infiltration and consolidation over right middle lobe, suspected pne
umonia related. Empirical antibiotics as Cravit and Tazocin were kept.However, desaturation to around 75% was
noted around 17:30. s/p ambu-bagging for 30 minutes and oxygenation improved some. Nonrebreathing mask was ke
pt. His family confirmed DNR except medication and refused hemodialysis. Antibiotics as Meropenem, Cravit, and
Micafungin were administered. On the next day morning, on 03/02, patient still had hypotension and desaturati
on. He became comatose. The family refused invasive treatment and agreed withe palliative treatment. In the af
ternoon, on 2021/03/02, at 13:40PM, patient was found pulselessn and no spontaneous breath. Fixed pupil withou
t light reflex, he was then pronounced death. Blood culture on 2021/3/4 grew Candida glabrata.