1. MGR 내분비내과 R3 진상욱 다발성 골통증을 주소로 내원한 53 세 여자환자

2. Chief Complaint 다발성 골통증 onset : 2008 년 1 월경 Present Illness 2005 년 4 월 양측 골반부위 통증으로 서울 성심병원에서 AVN 으로 진단받 고 bone graft at Rt. hip joint 시행 받음. 이후에도 증상 지속되어 2006 년 12 월 전남대 병원에서 THR both 시행 받음. 이후 통증 완화되었으나 오 른쪽 다리 절면서 걸었다고 함. 2008 년 1 월초부터 다시 양측 발목통증 발 생했고 발등부위까지 통증 악화되었으며 10 월경부터 양측 어깨, 팔, 손 부위로 통증 부위 확대되어 본원 정형외과 외래 방문 후 시행한 bone scan, BMD 에서 metabolic bone disease 의심되어 내분비 내과 입원함. 11850271 하 O 순 F/53 Admission on 2008.12.17

3. Past medical history Past medical history DM / HTN / Tb / HB ( - / - / - / - ) 2005 년 9 월 ( 서울성심병원 ) Core decompression with bone graft, AVN at Rt. Hip joint 2006 년 12 월 ( 전남대병원 ) THR both Drug history : none Personal history smoking (-) alcohol (-) menopause : 3 년 전

4. Family history Lung cncer

5. Review of System General fatigue (-) febrile sense (-) edema(-) weight change (+) : 70 → 65kg for 1 year Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) Eye & ENT visual disturbance (-) tinnitus (-) nasal obstruction(-) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

6. Review of System Gastrointestinal A/N/V/D/C (-/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) polydipsia (-) Urinary dysuria (-) frequency (-) urgency (-) residual urine sense (-) flank pain (-) nocturia(-) polyuria (+) foamy urine(+) Musculoskeletal multiple bone pain (both knees, ankles, dorsum of foot, both shoulders, both humerus) : 내원 20 일전 (08 년 11 월말 ) 부터 ABR 중임 Neurologic syncope (-) seizure (-) dizziness (-) numbness(-)

7. Physical Examination Vital sign 130/80 – 78 회 /min – 20 회 /min – 36°c weight : 65kg height : 157cm BMI : 26.2kg/m 2 General alert consciousness acutely ill-looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT isocoric pupil with PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

8. Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and flat abdomen normoactive bowel sound no tenderness / rebound tenderness no palpable mass no abdominal bruit no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-)

10. Initial Lab Findings CBC/DC 9000/mm² - 13.2g/dl - 35.4% - 377K (seg 72.7%) aPTT 28.8 PT (INR) 12.3(0.93)Chemistry AST/ALT 13/10 IU/LBUN/Cr 11/1.1mg/dL ALP/GGT 405/25IU/L Na/K/Cl 141/2.9/109mmol/L Glucose 178mg/dL Ca/P/Mg 8.5/1.6/2.5mg/dL Prot/Alb 7.1/4.7g/dL Uric acid 1.6mg/dL LD/CK 289/19U/L T-chol 207mg/dL U/A RBC 0~1/HPF WBC 2~4/HPF pH 6.5 Blood (+) Protein (+) Glucose (+++) Ketone (+/-) SG 1.039ABGA 7.343-35.3-18.7-97.7 Anion gap 13.3

11. Chest XR

12. EKG

16. Problem List 1. multiple bone pain 2. proteinuria 3. hypokalemia with metabolic acidosis 4. hyperglycemia

17. Initial Assessment and Plans 1. multiple bone pain due to metabolic bone disease Osteomalacia vitamin D deficiency hypophosphatemia Hyperparathyroidism Thyrotoxicosis Plan : Hormonal evaluation 1,25(OH) 2 vitamin and 25(OH)vitamin D TFT and PTH X ray evaluation (if needed)

18. Initial Assessment and Plans 2. Proteinuria 3. Hypokalemia with metabolic acidosis 24 hours urine collection (protein, creatinine) calculate TTKG abdominal sonography 4. Hyperglycemia check OGTT, HbA1c, FBS and pp2h

19. PTH : 10.9 pg/ml (13~54 pg/ml) PTH : 10.9 pg/ml (13~54 pg/ml) 1,25(OH) Vit D : 32.9 pg/mL (20.1~46.2 pg/mL) 1,25(OH) Vit D : 32.9 pg/mL (20.1~46.2 pg/mL) 25(OH) Vit D : 41.22 ng/mL (7.6~75.0 ng/mL) 25(OH) Vit D : 41.22 ng/mL (7.6~75.0 ng/mL) T3 : 138 ng/dL (80~200 ng/dL) T3 : 138 ng/dL (80~200 ng/dL) FT4 : 0.86 ng/dL (0.77~1.94 ng/dL) FT4 : 0.86 ng/dL (0.77~1.94 ng/dL) TSH : 0.98 uU/mL (0.30~4.00 uU/mL) TSH : 0.98 uU/mL (0.30~4.00 uU/mL) Lab Findings

20. 24hrs urine collection Protein (40~150mg/day) 3941 Glucose (500~1500mg/day) 47798 Creatinine (800~1800mg/day) 711 Uric acid (250~750mg/day) 660 Urea nitrogen (6~17g/day) 3 Crcl49.9 Serum Cr1.0 Urine Cr38 Urine vol.1890 Ca (100~240mg/day) 455 P (900~1300mg/day) 1194 K (40~80mmol/day) 45 Cl (110~250mmol/day) 138 Mg (12~17mg/dL) 91 Na (mmol/day) 159 Lab Findings

22. IgG : 482 mg/dL (694~1618 mg/dL) IgG : 482 mg/dL (694~1618 mg/dL) IgA : 24.8 mg/dL (68~378 mg/dL) IgA : 24.8 mg/dL (68~378 mg/dL) IgM : 19.1mg/dL (60~263 mg/dL) IgM : 19.1mg/dL (60~263 mg/dL) IgE : 17.2 IU/ml (~100 IU/ml) IgE : 17.2 IU/ml (~100 IU/ml) C3 : 117 mg/dL (88~201 mg/dL) C3 : 117 mg/dL (88~201 mg/dL) C4 : 28.5 (16~47) C4 : 28.5 (16~47) C-ANCA : negative C-ANCA : negative P-ANCA : negative P-ANCA : negative ANA : non-reactive ANA : non-reactive ß2 microglobulin : > 32 mg/L (Cr 0.9 g/day) ß2 microglobulin : > 32 mg/L (Cr 0.9 g/day) Lab Findings

23. TTKG =K+(U) /K+(P) ÷ Osm(U)/Osm(P) = 4.35

26. Renal Biopsy

31. Furosemide 30mg oral Furosemide 30mg oral Lasix Loading Test 04hrs pH5.5 Specific gravity1.0331.031

32. osteomalacia due to Fanconi syndrome - - hypophosphatemia - - hypokalemia - - phosphaturia - - glycosuria - - proteinuria / aminoaciduria

44. Final Diagnosis ostemalacia Fanconi syndrome multiple myeloma