1. 허리 통증 및 신장의 감소를 주소로 내원한 26 세 여자 환자 Dept. of Endocrinology and Metabolism

2. 11797996 김 O 애 (F/26) Adm. : 06.4.3 Chief Complain: 허리 통증 신장의 감소 신장의 감소 (onset: 17 개월 전 ) (onset: 17 개월 전 ) Present Illness: 평소 특이 병력 없이 건강히 지내던 환자 환자는 임신 8 주 ( 내원 25 개월전 ) 부터 간헐적인 허리 통증 있었으나 특별한 치료 받지 않고 지냈으며 허리 통증이 지속적으로 심해졌으나 이에 대한 특별한 검사 나 치료를 시행하지 않음 내원 17 개월 전 첫아이 출산 전 혈압이 높아서 pregnancy-induced hypertension 으로 치료받은 과거 력

3. 11823681 김 O 애 (F/26) Adm. : 06.4.3 Present Illness (cont’d): 환자는 출산 후에도 정상적인 생활이 불가능할 정도의 극심한 허리 통증이 지속적으로 심해져서 개인의원 방 문함 15 개월 전 ( 출산 2 개월 후 ) 개인의원에서 시행한 spine X ray 에서 심한 골다공증 및 흉추, 요추의 다발성 압박 골절 진단받고 약물치료 시작 환자는 임신시부터 진행된 튼살이 출산 후에도 남아있 어 이에 대해 개인 성형외과에서 상담하던 중 상기 주 소에 대한 정밀 검사를 우선적으로 권유받아 내원

4. 11823681 김 O 애 (F/26) Adm. : 06.4.3 Past medical history: DM (-), Hypertension (±), TB (-), Hepatitis (-)  patient denied  patient denied 최근 Osteoporosis (+), Spine compression Fractures (+) 최근 Osteoporosis (+), Spine compression Fractures (+) 복부의 튼살 (+) 복부의 튼살 (+) Personal History: Alcohol (-), Smoking (-) Alcohol (-), Smoking (-)

5. 11823681 김 O 애 (F/26) Adm. : 06.4.3 Family history: Drug history: All medication denied except All medication denied except Ca 2+ and Vitamin D supplements Ca 2+ and Vitamin D supplements

6. Review of System General: fever (-) chill (-) fatigue (-) myalgia (-) weight gain (+) : +30 kg (+10 after delivery) weight gain (+) : +30 kg (+10 after delivery) shortening of stature (+): 7cm (164 cm  157cm) shortening of stature (+): 7cm (164 cm  157cm) Skin: facial rash, flush(+) pigmentation(-) abdominal skin striae (+) : progressive abdominal skin striae (+) : progressive H&N: headache(-)dizziness(-)neck stiffness(-) neck pain(-) sore throat(-) neck pain(-) sore throat(-) Eye&ENT: visual disturbance(-) hearing loss(-) Breast: pain(-)lump(-)discharge(-)

7. Review of System Respiatory: cough(-) sputum(-) dyspnea(-) Cardiac: angina(-) orthopnea(-) palpiation(-) Gastointestinal: anorexia (-) nausea(-) vomiting(-) diarrhea(-) constipaition(-) diarrhea(-) constipaition(-) abdominal pain(-) abdominal pain(-) Genitourinary: frequency (-) urgency (-) dysuria (-) amenorrhea (+) – for 15 mo, 최근 재개 amenorrhea (+) – for 15 mo, 최근 재개 Musculoskeletal: back pain (+) progressive, 개인의원 진료후 다소 호전 progressive, 개인의원 진료후 다소 호전

8. Physical Examination Vital sign: 100/70mmHg – 80bpm – 20bpm – 36.5°C Height: 154 cm Weight: 50 kg, BMI: 21.1 kg/m 2 Height: 154 cm Weight: 50 kg, BMI: 21.1 kg/m 2 G/A : alert consciousness, acutely ill-looking appearance moon face(±): suspicious moon face(±): suspicious buffalo hump(-) petechia(-) buffalo hump(-) petechia(-) Skin : facial rash (+) pigmentation (-) abdominal striae (+): purple colored abdominal striae (+): purple colored

9. Physical Examination H&N : palpable LNs (-) thyroid enlargement (-) neck stiffness (-) neck stiffness (-) Eye&ENT: isocoric pupil with PLR (++/++) pinkish conjuntiva whitish sclera pinkish conjuntiva whitish sclera visual disturbance(-) hearing loss(-) visual disturbance(-) hearing loss(-) pharingeal injection(-) pharingeal injection(-) Chest : regular heart beat without murmur clear breath sound without crackle clear breath sound without crackle

10. Physical Examination Abdomen: soft & slightly distended tenderness (-) rebound tenderness (-) tenderness (-) rebound tenderness (-) hyperactive bowel sound (+) striae (+) hyperactive bowel sound (+) striae (+) Back & extremities: no CVA tenderness pretibial pitting edema (-/-) pretibial pitting edema (-/-) back tenderness (+) numbness (-) back tenderness (+) numbness (-) redness (-), swelling (-) redness (-), swelling (-) Neurology: facial palsy (-), DTR (++/++) motor sensory motor sensory VV VV 100

11. Gross Feature No image available - Patient strongly refused taking a photo - - Patient strongly refused taking a photo -

12. Initial Assessments # Assessments 1. Multiple T-L spine compression fractures 2. Osteoporosis 3. Cushing’s syndrome d/t iatrogenic d/t iatrogenic d/t pituitary adenoma d/t pituitary adenoma d/t adrenal neoplasm d/t adrenal neoplasm

13. Plan # plan - Bone scan, BMD, spine MRI - Bone Markers: pyridinoline(U), osteocalcin(S) - 24hr urine Cortisol, ACTH(S) - 5 days Dexamethasone suppression test - Abdomen CT and Sella MRI, if indicated

14. Any Question or Comments?

15. Laboratory Findings at Admission CBC/DC : 5610/mm 3 – 14.4 g/dL – 43% - 285k/mm 3 (seg. 70.4 %) 5610/mm 3 – 14.4 g/dL – 43% - 285k/mm 3 (seg. 70.4 %) PT/PTT: 14.2 sec (INR 1.13) / 49 sec (control 33 sec) PT/PTT: 14.2 sec (INR 1.13) / 49 sec (control 33 sec)Chemistry Total/Direct bilirubin 0.86 / 0.16 mg/dL (ref. 0.0~1.1) Total/Direct bilirubin 0.86 / 0.16 mg/dL (ref. 0.0~1.1) Total Cholesterol 214 mg/dL (ref. <200) Total Cholesterol 214 mg/dL (ref. <200) ALP 80 mg/dL (ref. 39~117) ALP 80 mg/dL (ref. 39~117) AST / ALT 19 / 15 U/L (ref. <40 each) AST / ALT 19 / 15 U/L (ref. <40 each) T-protein/albumin 6.4 / 3.6 g/dL (ref. 5.8~8.0/3.1~5.2) T-protein/albumin 6.4 / 3.6 g/dL (ref. 5.8~8.0/3.1~5.2) Glucose105 mg/dL (ref. <100) Glucose105 mg/dL (ref. <100) BUN / Cr5 / 0.6 mg/dL (ref. 8~23/0.6~1.2) BUN / Cr5 / 0.6 mg/dL (ref. 8~23/0.6~1.2) Na/ K / Cl142 / 3.8 / 107 mmol/L Na/ K / Cl142 / 3.8 / 107 mmol/L Ca/ P / Mg 9.3 / 2.5 / 2.4 mg/dL Ca/ P / Mg 9.3 / 2.5 / 2.4 mg/dL

16. Laboratory Findings at Admission Ionized Calcium : 1.13 mmol/L (ref. 1.12~1.30) U/A : Occult blood : negative Protein : negative Occult blood : negative Protein : negative Glucose : 0.1 pH : 7.0 Glucose : 0.1 pH : 7.0 Specific Gravity: 1.010 (ref. 1.010~1.025) Specific Gravity: 1.010 (ref. 1.010~1.025) RBC : 0~1/HPF WBC : 0~1/HPF RBC : 0~1/HPF WBC : 0~1/HPF 24hrs Urine collection : Protein : 105 mg/day Creatinine : 526 mg/day Protein : 105 mg/day Creatinine : 526 mg/day CrCl : 60.9 ml/min Urine Vol. : 750 ml CrCl : 60.9 ml/min Urine Vol. : 750 ml Ca / P / Mg : 107 / 224 / 47 (ref. 100~240 / 900~1300 / 12~17) Ca / P / Mg : 107 / 224 / 47 (ref. 100~240 / 900~1300 / 12~17)

17. EKG at Admission

18. Plain Radiography: Chest PA

19. Plain Radiography: T-L spine

20. Plain Radiography: Whole spine

21. Previous Spine MR at other hospital

22. Bone Scan

23. Bone Densitometer (BMD)

24. Spine MRI

26. Abdominal CT scan

27. Endocrinologic LAB findings ACTH/Cortisol ACTH : not determined yet Cortisol (s): 20.9 ug/dL (8 am) (ref. 7~25) 24.0 ug/dL (4 pm) (ref. 3.5~10) 24.0 ug/dL (4 pm) (ref. 3.5~10) Bone Markers Osteocalcin (S) : 2.3 ng/mL (ref. 3.2~12.2) Pyridinoline (U) : 5.3 ng/mL (ref. 2.5~6.5) - creatinine (3hrs) : 325 mg - creatinine (3hrs) : 325 mg

28. Endocrinologic LAB findings OGTT 0 30 60 90 120 0 30 60 90 120 Glucose 115 216 235 205 221 mg/dL Glucose 115 216 235 205 221 mg/dL Insulin 11.9 75.1 μU/mL Insulin 11.9 75.1 μU/mL C-peptide Not determined yet C-peptide Not determined yet

29. Final Diagnosis Multiple T-L spine compression fracture Osteoporosis Cushing syndrome d/t adrenal neoplasm d/t adrenal neoplasm Type 2 Diabetes Mellitus

30. Thank you for your attention