MGR 혈액종양내과

이 O 예 (F/76) ADM C.C) 구강내출혈 o/s) 2 일전 P.I) 평소 출혈성 경향 보이지 않던 환자로 내원 20 일전 부터 멍이 잘 생기는 증상 있었고 2 일 전부터 구강내출혈 있어 근처 서산의료원 방문. 당시 CBC 상 platelet 2000/mm 3 으로 감소 소견 보여 이에 대한 검사와 치료 위해 본원으로 전원 됨. (2004 년 11 월 혈액 검사상 특이 소견 없었다고 함 - 보호자 진술 ) 한달 전부터 기침, 가래 증상으로 근처 내과의원서 약 처방 받아 복용함. 슬관절 통증으로 20 일전부터 근처 정형외과의원서 처방약 복용 중임.

PMHx) DM/pul.Tb/hepatits(-/-/-) liver disease(-) HTN(+) :10 년 전 진단 ischemic heart disease(+):3 년전 진단 bronchial asthma(+):2 년전 진단 op. Hx(-) PHx) alcohol(-) smoking(-) travel Hx.(-)

Drug Hx. Irbesartan 150mg Amlodipine 5mg Furosemide 40mg Spironolactone 25mg Aspirin 100mg Clopidogrel 75mg Ginko biloba Ext. 40mg Almagate 500mg Domperidone 10mg Prednisolone 10mg/day Cough syrup Seretide(DPI) Cefaclor 750mg/day Glucosamine 250mg Chondroitin sod. 40mg

Review of system General fever(-) chill(-) sweating(-) myalgia(-) Skin petechia(+) : both lower leg itching(-) easy bruising(+): 20days ago H/N headache(-) epistaxis(-) visual disturbance(-) sorethroat(-) sore mouth(-) trauma(-) bleeding, oral cavity(+) ecchymosis(+): lt. cheek & submandibular area swelling, both cheek(+/+) Chest dyspnea on exertion (+) chest pain(-) palpitation(-) cough(+) sputum(+) GI A/N/V/D/C(-/-/-/-/-) oral intake: decreased abdominal distension(-) abdominal pain(-) melena(+) bloody stool(-) GU dysuria(-) hematuria(-) postmenopausal state(+) M/S flank pain(-/-) arthralgia(-) paresthesia(-) generalized edema(-) NR dizziness(-) weakness(-)

Physical examination V/s) 90/60mmHg-60 회 /min-20 회 /min-36.3°C Bwt. 60 Kg Ht. 160cm BMI 23.4 Kg/m 2 General alert consciousness acutely ill-looking appearance Skin thin(+) decreased skin turgor(+) pethchia(+) : both lower leg H/N ecchymosis(+): both cheek & lt. submandibular both cheek: swelling(+) pain(-) tenderness(-) no cervical LN enlargement no neck vein engorgement E/ENT isocoric pupil with PLR(+/+) pinkish conjunctiva(+/+) oral cavity : blood clot(+) mucosal hematoma, both cheek(+/+)

Chest clear breath sound without rale or wheezing regular heart beat without murmur axillary LN enlargement(-/-) Abd normoactive bowel sound soft & obese abdomen no splenomegaly no hepatomegaly abdominal tenderness/rebound tenderness(-/-) DRE : melena(-), hematichezia(-) B/Ext CVA tenderness(-/-) pitting edema(-/-) inguinal LN enlargement(-/-) NR Babinski sign(-/-) neck stiffness(-) motor & sensory : intact

Initial lab. finding CBC 6500/mm g/dL-32.4%-2K (seg 66.7 % lympho 16.3 % mono 12.2 % eosino 4.1 % blast 0 %) (MCV 89.5 fL MCH 29.9 pg) aPTT 40 C 33 PT 14.1S 87 (INR 1.09) Reticulocyte 1.66% –corrected reti. 1.19% –Reticulocyte production index 0.79 TB/DB 0.5/0.1 mgdL AST/ALT 23/17 U/L ALP/GGT 40/14 U/L prot/alb 6.0/3.7 g/dL glucose 127 mg/dL LD/CK 360/103 U/L BUN/Cr 25/0.7 mg/dL Na/K/Cl 131/3.4/101 mmol/L UA) RBC 0-1/WBC 0-1

Chest PA

Initial problem list #1. oral mucosal bleeding & hematoma #2. petechia, both lower leg #3. hypotension #4. thrombocytopenia #5. anemia #6. known HTN #7. known ischemic heart disease #8. known bronchial asthma

Initial assessment #1. thrombocytopenia, d/t drug r/o infection r/o hematologic malignancy r/o connective tissue disease r/o idiopathic thrombocytopenic purpura #2. anemia d/t oral mucosal bleeding d/t iron deficiency anemia d/t chronic illness #3. HTN #4. ischemic heart disease #5. bronchial asthma

Initial diagnostic work up #1. thrombocytopenia –drug information –viral marker(HBV, HCV, HIV, CMV, EBV) –toxoplasma IgM –serologic marker(ANA, VDRL, IgG, IgM, IgA, RF, cryoglobulin, CRP, ESR) –bone marrow study –anti-platelet Ab. #2. anemia –PBS, serum iron, TIBC, ferritin –Vitamin B 12, folate

Initial therapeutic plan #1. –discontinuation of self drug –BP control Hydration with saline/vol. expander –transfusion (platelet concentration) –local compression at bleeding site

Drug Irbesartan 150mg Amlodipine 5mg Furosemide 40mg Spironolactone 25mg Aspirin 100mg Clopidogrel 75mg Ginko biloba Ext. 40mg Almagate 500mg Domperidone 10mg Prednisolone 10mg/day Cough syrup Seretide(DPI) Cefaclor 750mg/day Glucosamine 250mg Chondroitin sod. 40mg

Lab. finding HBsAg/anti-HBsAb/anti-HBc IgG(-/-/-) Anti-HCV(-) anti-HIV(-) Anti-CMV IgM(-) EBV EBNA(-) EBV EA-DR IgM/IgG(-/-) EBV VCA IgM/IgG(-/+) Toxoplasma IgM(-) VDRL(-) ANA(-) RF <20 IU/mL IgG/A/M 926/146/50 mg/dL cryoglobulin(-) Antiplatelet Ab(-) S-iron 73 ug/dL TIBC 317 ug/dL transferrin saturation 23% ferritin 25 ng/mL vitamin B pg/mL folate 10.2 ng/mL PBS : hypochromocyte

Abdominal sono

BM study PC 10 5units Clinical course PC 3 5 unitsPC 8 units

Bone marrow study

Clinical course PC units PC 8 6 units BM study Prednisolone 60mg/day

Final diagnosis Idiopathic thrombocytopenic purpura r/o drug-induced thrombocytopenia Known HTN Known ischemic heart disease Known bronchial asthma