1. 같은 양상, 다른 원인 3 인 3 색의 Hyponatremia 내분비대사내과 R2 박유민 /prof. 이상열

2. C.C 기침 onset 3 일 전 P.I 내원 3 일 전 시작된 기침과 화농성 가래 악화되어 응급실 방문 PMHx DM/HTN/TB/ hepatitis (+/+/-/-) DM : 10 년 전 진단, HTN : 5 년 전 진단 Stable angina s/p PCI at pLAD (2006 년 11 월 ) LV aneurysm a/w old MI (2011 년 ) Op Hx (+) : cholecystectomy (10 년 전 ) Medication : Losartan 25mg qdAspirin 100mg qd Atorvastatin 10mg qdLevosulpiride 25mg bid Vildagliptin/metformin 50/1000mg bid Glimepiride 1mg qd CASE 1. 김 O 심 F/76 11283577

3. Review of systems Fever/chilling (-) Cough/sputum/dyspnea (+/+/+) Physical examination Vital sign : 140/120mmHg - 98/min - 30/min - 36.2 ℃ - 93% (RA) Acutely-ill looking appearance Mentality : alert Dehydrated tongue (+) Coarse breathing sound c crackle, RLLF Regular but rapid heartbeat s murmur CASE 1 (F/76)

4. CBC/DC 14,730/mm² - 13.5 g/dl – 42% - 138K (Seg. 87%) Chemistry Prot/Alb6.8/4.0 g/dLBUN/Cr37/1.4 mg/dL TB/DB0.60/0.31 mg/dLNa/K/Cl124/5.1/89mEq/L AST/ALT45/42 IU/LCa/P/Mg9.1/7.5/2.7 ALP/γGT244/72 IU/LCRP20.22 mg/dL Glucose623 mg/dLCK/CK-MB/TnI73/5.3/0.03 ng/dL UA Occult blood +Protein –Glucose +++Keton +++ RBC 2-4/HFPWBC 0-1/HPF ABGA pH 7.0 – pCO2 9.4mmHg – pO2 98mmHg – HCO3 6.1mmol/L – SaO2 95% () Baseline Cr 0.9 FENa 0.66%, FEBUN 32% Baseline Cr 0.9 FENa 0.66%, FEBUN 32% CASE 1 (F/76) serum AG 29

5. CASE 1 (F/76)

7. Problem list #1. Hyperglycemia #2. Metabolic acidosis (AG 29) #3. h/o DM #4. Cough, sputum, dyspnea #5. Elevated CRP #6. RLL zone consolidation #7. Hyponatremia (Corrected 137) #8. Elevated Cr #9. h/o LV aneurysm a/w old MI #10. h/o HTN Assessment #1. Diabetic ketoacidosis #2. Peumonia, RLL #3. Pseudohyponatremia #4. AKI (Prerenal type) #5. LV aneurysm a/w old MI #7. HTN CASE 1 (F/76)

8. C.C 구토 Onset (remote/recent) 2 주 /2 일 전 P.I 생후 2 개월 Congenital adrenal hyperplasia (21-OH deficiency) 진단 받고 치료 중이던 자로, 2 주 전부터 구역과 구토 있었고 2 일 전부터는 먹을 때마다 증상 발생하여 내원 PMHx DM/HTN/TB/ hepatitis (-/-/-/-) Congenital adrenal hyperplasia (21-OH deficiency) (1996 년 ) Op Hx : Bilateral adrenalectomy (2006 년 ) Medication : Hydrocortisone 30mg qd (2006 년부터 변경없음 ) Fludrocortisone 0.1mg qd (1996 년부터 변경없음 ) Ca citrate/Cholecalciferol 750/4 mg qd (2006 년부터 변경없음 ) CASE 2. 류 O 현 M/27 10582460

9. CASE 2 (M/27) 20042006

10. Review of systems Generalized weakness(+) Anorexia/Nausea/Vomiting (+/+/+) Diarrhea/Constipation (-/+) Physical examination Vital sign : 100/70mmHg - 88/min - 20/min - 36.1 ℃ - 98% (RA) Pigmented skin (+) Normoactive bowel sound (+) Abdominal Td/rTd (-/-) CASE 2 (M/27)

11. CBC/DC 8,260/mm² - 17.6 g/dl – 49.7% - 455K (Seg. 46%) Chemistry Prot/Alb8.3/4.6 g/dLBUN/Cr27/1.0 mg AST/ALT45/33 IU/LNa/K/Cl120/4.8/86 mEq/L ALP123 IU/LCa/P/Mg9.8/4.3/2.2 mg/dL CRP<0.3 mg/dL UA Occult blood -Protein -Glucose -Keton ++ RBC 0-1/HFPWBC 0-1/HPF CASE 2 (M/27)

12. Problem list #1. Hyponatremia #2. h/o CAH (21-OH defeciency) s/p bilateral adrenalectomy Assessment #1. Hyponatremia a/w Adrenal insufficiency CASE 2 (M/27)

13. C.C 구토 Onset (remote/recent) 1 년 전 /2 일 전 P.I 최근 1 년 동안 전신쇠약감 및 우울감 있었던 자로 이틀 전 인근 정신건강의학과 진료 후 약제 변경하여 복용 시작하였으며 이후 증상 더 심해지고 구역, 구토 지속되어 응급실 방문함. PMHx DM/HTN/TB/ hepatitis (-/+/-/-) Hypothyroidism : 2009 년 진단 MDD Op Hx (+) : Spinal stenosis 로 L spine Op CASE 3. 조 O 숙 F/78 10890293

14. Drug Hx Rebamipide Alverine citrate Tofisopam 50mg bid Lorazepam 0.5mg qd Paroxetine 10mg qd Dimenhydrinate Aluminum hydroxide Calcium citrate 1250mg Calciferol 10mg qd Eperisone Celecoxib Limaprost Eprosartan/thiazide 600mg/12.5 qd Levothyroxine 75mcg qd Clopidogrel 75mg qd Rosuvastatin 10mg qd Donepezil 5mg qd Tianeptine 12.5mg bid CASE 3 (F/78)

15. Review of systems Generalized weakness (+) Anorexia/Nausea/Vomiting (+/+/+) Diarrhea/Constipation (-/-) Depressive mood (+) Physical examination Vital sign : 140/80mmHg - 80/min - 20/min - 36.0 ℃ - 98% (RA) Normoactive bowel sound Abdominal Td/rTd(-/-) CASE 3 (F/78)

16. CBC/DC 7,860/mm² - 12.5 g/dl – 36.1% - 395K (Seg. 75.7%) Chemistry Prot/Alb6.9/4.3 g/dL BUN/Cr19/0.8 mg/dL TB/DB0.78/0.23 mg/dLNa/K/Cl120/3.4/86 mEq/L AST/ALT22/13 IU/LCa/P/Mg8.9/3.2/2.0 mg/dL ALP/γGT123/22 IU/LCRP<0.3 mg/dL UA Occult blood -Protein -Glucose -Keton ++ RBC 2-4/HFPWBC 0-1/HPF CASE 3 (F/78)

17. Problem list #1. Generalized weakness #2. Nausea #3. Vomiting #4. Hyponatremia #5. h/o Hypothyroidism #6. h/o HTN #7. h/o MDD #8. Multiple drug user Assessment #1. Hyponatremia Drug related (most likely) Hypothyroidism (less likely) #2. Hypothyroidism #3. HTN #4. Major depressive disorder CASE 3 (F/78)

19. Diagnostic plan Corrected Na, Urine & serum Osm, urine electrolyte TFT, Rapid ACTH stimulation test Recheck medication history LFT, CRP f/u Abdominal imaging, if needed Therapeutic plan Calculate sodium deficit & sodium supply, Correction of underlying etiology Stop culprit drugs Plan

20. Clinical course

21. Case1. * Presenting Sx : cough/sputum * Underlying disease : DM, HTN * Initial Na 124 / Glucose 623(Corrected Na 137) Serum Osm 326 (Osm/kg) Urine Osm 541 (Osm/kg) Urine Na 24 mmol/L DKA Pseudohyponatremia Pneumonia Prerenal AKI HbA1c =13.6 %

22. Corrected 134 (Glucose 632) Corrected 141 (Glucose 200) Procalcitonin 17.30ng/mL Blood, sputum culture Krebsiella pneumoiae Intubation Levofloxacin 750mg + 500mg eod NS 200cc/hr CASE 1 (F/76) HD1

23. Procalcitonin 17.30ng/mL Blood, sputum culture Krebsiella pneumoiae proBNP 50326 pg/mL f/u TTE : EF 52 -> 38%, RWMA at LAD territory Levofloxacin 750mg + 500mg eod Pip/taz 2.25g q 6hrs NS 40cc/hrNS 200cc/hr Furosemide 20mg x 10@ CASE 1 (F/76) HD1 HD5HD4 HD3HD2 Tolvaptan 15mg qd 030min60min HbA1c 13.6 % S-cortisol9.631.432.2 Aldosterone7.574.660.5 TSH0.82 Free T42.05

24. Case1. * Presenting Sx : cough/sputum * Underlying disease : DM, HTN * Na 129 / Glucose 180 (Corrected Na 130) Serum Osm 494 (Osm/kg) Urine Osm 286 (Osm/kg) The diagnostic approach to hyponatremia Harrison’s principle of internal medicine, 18ed. UNa29 DKA -> Resolved Pneumonia sepsis Prerenal AKI -> resolved + HF

25. Case2. * Presenting Sx : nausea/vomiting * Underlying disease Congenital adrenal hyperplasia s/p bilateral adrenalectomy * Initial Na 120 Serum Osm 273 (Osm/kg) Urine Osm 912 (Osm/kg) The diagnostic approach to hyponatremia Harrison’s principle of internal medicine, 18ed. UNa138 Adrenal insufficiency Congenital adrenal hyperplasia s/p bilateral adrenalectomy 1998-082006-032012-062013-03 S-cortisol5.25.119.53.1 S-ACTH1262118.240.7887.2 Aldosterone7812831.543.5 PRA6.77.572.037.9

26. Hydrocortisone 250mg iv HD1 Hydrocortisone 100mg iv qd HD2-4 po 20mg- 10mg HD5 PDL 15-10-5mg po HD6~ Fludrocortisone 0.1mg qd HD6~ 3% saline 20cc/hr NS 60cc/hr NS 40cc/hr HD1 HD3 HD2 HD9 HD5 Case2. BW 57kg, Sodium deficit = 480mEq

27. Case3. * Presenting Sx : nausea/vomiting * Underlying disease HTN,hypothyroidism, depression * Initial Na 120 Serum Osm 261 (Osm/kg) Urine Osm 683 (Osm/kg) The diagnostic approach to hyponatremia Harrison’s principle of internal medicine, 18ed. UNa130 Drug induced hyponatremia r/o SIADH Hypothyroidism 030min60min S-cortisol9.635.444.3 Aldosterone55.5128.784.5 PRA1.5 TSH3.48 Free T41.56

28. Rebamipide Alverine citrate Tofisopam 50mg bid Lorazepam 0.5mg qd Paroxetine 10mg qd Dimenhydrinate Aluminum hydroxide Calcium citrate 1250mg Calciferol 10mg qd Eperisone Celecoxib Limaprost Eprosartan/thiazide 600mg/12.5 qd Levothyroxine 75mcg qd Clopidogrel 75mg qd Rosuvastatin 10mg qd Donepezil 5mg qd Tianeptine 12.5mg bid

29. NS 120cc/hr 3% saline 30cc/hr NS 60cc/hr Case3. BW 70kg, female, Sodium deficit = 350mEq

30. Medication review Rebamipide Alverine citrate Tofisopam 50mg bid Lorazepam 0.5mg qd Paroxetine 10mg qd Dimenhydrinate Aluminum hydroxide Eprosartan/thiazide 600mg/12.5 qd Levothyroxine 75mcg qd Clopidogrel 75mg qd Rosuvastatin 10mg qd Donepezil 5mg qd Tianeptine 12.5mg bid Calcium citrate 1250mg Calciferol 10mg qd Eperisone Celecoxib Limaprost Harrison’s principle of internal medicine, 18ed.

31. NS 120cc/hr 3% saline 30cc/hr NS 60cc/hr

32. Final diagnosis Hyponatremia DKA Pneumonia sepsis HF Drug induced SIADH Adrenal insufficiency