☆網路內科繼續教育☆有效期間：民國103年05月01日至103年05月31日止  CaseDiscussionPresentationofCaseAn86-year-oldman,previouslyhealthy,presentedtotheemergencydepartment(ED)attheishospitalbecauseofconsciousnessdisturbance,slurredspeech,disorientationandtremorofthebilaterallowerextremities(paroxysmal,every10-20seconds)for1day.Hehadreceivedadiagnosedofbenignprostatichyperplasia,forwhichheunderwentsurgicalintervention2monthspriortothisadmission.Bloodyurineanddysuriadevelopedaftertheoperation,associatedwithurinaryfrequencyandurgency.Onemonthpriortothisadmission,hestumbledwhenwalkingtotoilet,resultinginfractureoftherightfemoralneck.Openreductioninternalfixation(ORIF)wasperformedandhewassuccessfullydischarged.Butthepatientwasfoundtohaverapidfunctionaldeclineinrecentdays,withdisorientationandinvoluntarylimbsmovement.Forthisreason,hewasbroughttoourED.Onexamination,thevitalsignswerenormalbutthepatienthadfluctuationinconsciousnesswithdisorientationtotime,peopleandplace.Nomotorweaknesswasnoted.BrainMRIshowednointracranialhemorrhage.Anelectroencephalography(EEG)discloseddiffusecorticaldysfunctionwithoutepilepsywave.Laboratoryexamshowedawhite-cellcountof9520,pyuria(WBC>100/HPF)andbacteruria(4+).Adiagnosisofurinarytractinfectionwasmadeandcefuroximewasadministered,whichwaslaterchangedtoceftazidimewhenaurineculturegrewMorganellamoarganiithatwasresistanttocefuroxime.Duringthehospitalstay,tremorofthebilaterallowerlimbstremorimprovedgradually,butfluctuationinmentalfunctionpersistedforseveraldays,Afterthepatientcompletedantibiotictreatment,deliriumatnightwithweightlossstillpresented.Thearterialbloodgasshowedmetabolicalkalosis,whilebloodtestsforelectrolytes,NH3,andtumormarkerswereallwithinnormallimits.Intravenousfluidsupplementwascontinueduntilimprovementofmetabolicalkalosisandcorrectionofvolumedepletionwasobserved.Therewasnohydronephrosisormalignancybyaseriesofimagingexaminations.Heunderwentintermittentbladderirrigationperurologist’ssuggestion.Afteraprolongedhospitalstay,thedeliriumfinallyimprovedandhewassafelydi