Admission:  주소 근육통 onset) 1 주일 전  현병력 57 세 여자, 고혈압, 협심증으로 타병원 추적관찰 중인 자로 1 주일 전부터 시 작된 발열, 근육통으로 개인병원 방문함. 혈액검사에서 간기능 검사 수치 상승 (2,000 이상 ) 으로 상급 병원 권유받고 응 급실 통해 입원함.

 Past medical history DM/HTN/Tb/Hepatitis(-/+/-/-): 3 년전 고혈압 진단받음. Medication history: Medical medicine: carvedilol 12.5mg, indapamide 1.5mg qd Herbal medicine: none 건강식품 : none * 1 달 전 멧돼지 쓸개 절편을 소주에 타서 마심 Operation history(-)  Personal History Smoking(-), Alcohol(-)  Family History 간질환 가족력 없음. Past history

GeneralFever (+)Chill (-)Weight change (-) Fatigue(+)Sweating (-) Edema(-) SkinRash (-) Itching (-)Jaundice (-) Head/ENTHeadache (-)Sore throat (-)Nasal obstruction(-) Otalgia(-)Ear discharge(-)Hearing disturbance(-) Periocular swelling(-) RepiratoryCough (-)Sputum (-)Dyspnea (-) Hemoptysis (-) Pleuritic pain (-) Review of system 주 전 fever(+), 2 일 후 호전됨 입원 후 Fever(-)

CardiovascularChest pain (-)Palpitation (-)Orthopnea (-) GastrointestinalAnorexia (+) Nausea (+)Vomiting (-) Diarrhea (-)Constipation (-)Abdominal distension (-) Melena (-)Hematochezia (-)Hematemesis (-) Abdominal pain(+): epigastric, intermittent, squeezing UrogenitalFlank pain (-)Dysuria (-) Urgency (-) Frequency (-)Dark urine(-) NeuromuscularNumbness (-)Dizziness (-)Sleep disturbance(-) Weakness (-)Sensory loss (-)Arthralgia (-) Review of system 주 전 짙은 소변 입원 후 dark urine(-)

Ht : cmBW : 61.0 kgBMI : 26.3 kg/m2 Initial V/S110/70 mmHg - 85/min - 20/min – 36.0 ℃ – 99% GeneralAlert consciousness Acutely-ill looking appearance Head/ENTIsocoric pupil c pupil light reflex (++/++) Neck vein engorgement (-/-) Neck lymph node enlargement (-/-) Clear scelraPinkish conjunctiva ChestSymmetric chest expansion Regular heart beat without murmur Clear breathing sound without rale Physical examination - 1

AbdomenSoft and flat abdomen, No shifting dullness Normoactive bowel sound Abdominal tenderness (+): epigastric area, mild Rebound tenderness (-) Back/ExtCostovertebral angle tenderness (-/-) Pretibial pitting edema (-/-) Joint swelling/tenderness (-/-) Motor/Sensory Physical examination - 2 V V VV 100

Initial Lab Findings - 1  CBC/DC 6,970/ ㎕ (72.3%) – 12.1 g/dL – 271,000 / ㎕ PT INR 1.16aPTT 36.9 sec  Chemistry TB/DB1.43/1.05 mg/dLAST/ALT1414/1867 U/L ALP/rGT418/350 IU/LProt/Alb8.0/4.0 g/dL BUN/Cr24/1.0 mg/dLNa/K/Cl137/2.7/96 mmol/L Ca/P/Mg8.9/3.4/2.4 mg/dL LD/CK 1,491/51 U/L CRP4.18 mg/dLESR88

 Urinalysis Occult Blood -Protein +Glucose +- Urobilinogen ++ RBC 2~4 /HPFWBC many /HPFBacteria a few Initial Lab Findings - 2

Initial Chest X-ray ( )

Initial EKG

Initial problem list #1. acute hepatitis, r/o viral (HAV, HBV, HCV, HEV, EBV, CMV) r/o toxic r/o GB, biliary disease r/o autoimmune #2. stable angina #3. hypertension #4. asymptomatic bacteriuria

Causes of hepatitis Hepatology 2012; 55:447.

Harrison’s Principles of Intenal Medicine, 18e

Diagnostic & therapeutic plan (1) Hydration, supportive care Therapeutic plan Viral markers HAV IgG/IgM HBsAg, HBcAb, HBsAb(HBe Ag/Ab, HDV) HCV Ab HEV IgG/IgM EBV, CMV 검사 Autoimmune hepatitis lab ANA, SMA, LKM1 Ab, AMA, ANCA, ceruloplasmin Abdomen imaging AP sono Diagnostic plan #1. acute hepatitis, r/o viral (HAV, HBV, HCV, HEV, EBV, CMV) r/o toxic r/o GB, biliary disease r/o autoimmune

Diagnostic & therapeutic plan (2) #2. stable angina #3. hypertension #4. asymptomatic bacteriuria Meidcal treatment, 필요시 PCI Therapeutic plan EKG f/u, 필요시 TTE, CAG 고려 Diagnostic plan

Progress note – HD #7 ( ) #1. acute hepatitis, r/o viral, r/o toxic r/o GB, biliary disease r/o autoimmune S) febrile sense(-) myalgia(+) -> (-) nausea(+) -> (-) O) AP sono( ) : Mild fatty liver. Right renal cyst.

면역 검사 IgG(694~1618) mg/dL 1,920 IgA(68~378) mg/dL386 IgM(60~263) mg/dL239 IgE(~100) IU/mL<18 RA factor(~20) IU/mL <10 C-ANCA1 + P-ANCANegative ANA 1+ (speckle d) ANA( 정량 ) Negative 위탁 검사 Ceruloplasmin (16.2~35.6)mg/dL 28 Anti-mitocholdria AbNegative Anti-smooth m. AbNegative α- antitrypsin (90~200)mg/dL 120 Anti-LKM-1 AbNegative Viral markers HBs AgNegative Anti-HBs AbPositive Anit-HCV AbNegative Anti-HAV IgMNegative Anti-HAV IgGPositive Anti-CMV IgMNegative #1. acute hepatitis, r/o viral, r/o toxic r/o GB, biliary disease r/o autoimmune Progress note – HD #7 ( )

Location: epigastric Character: squeezing Duration: 30 sec ~ 1 min Radiating pain(-) Associated Sx(-) Aggravating factor: exertion Relieving factor: resting  cardiac angio CT 1. RCA : unremarkable (mid portion 에 motion artifact 많음 ) 2. LM : unremarkable 3. LAD : mid - myocardial bridging 4. LCX : distal - irregularity without significant stenosis Progress note – HD #7 ( ) #2. stable angin S) Epigastric pain O) TTE( ) : grade I diastolic dysfunction Normal heart size, LV function A) Stable angina P) CAG 시행

Clinical course Hydration & iv hepatotonics(1/16~17) po hepatotonics(1/16~2/28) 퇴원

Final diagnosis #1. Acute hepatitis E #2. Stable angina #3. Hypertension