1. MGR 심장내과 R 2 최윤영 / Prof. 김우식

2. 환자이름 : 임 O 자 (F/63) 입원일자 : 2014.05.12 주 호소 설사 onset ) 5 일전부터

3. 내원 6 개월전 (2013.11.11)  2013 년 11 월 진경환 내과에서 아래와 같은 소견으로 소화기내과에 의뢰된 환자임. “ 고혈압, 당뇨병으로 약물치료 중인 환자로 abdominal discomfort, dyspnea, diarrhea 등이 있어 약물 치료 했으나 호전 없어 의뢰합니다.”

4. 내원 6 개월전 (2013.11.14)  2013 년 11 월 소화기내과에서 위내시경, 대장내시경 및 abdominal CT 등 시행함 Gastric leiomyoma (r/o GIST) Edema, pleural effusion, ascites Diuretics 투여 하며 경과관찰 증상호전

5. 내원 5 개월전 (2013.12.18)  경희대병원으로 내원시 호소했던 Abdominal discomfort, diarrhea 등의 증상은 호전. Dyspnea 및 pitting edema 소견 지속. 2013.12.18 심장내과에 의뢰됨 P/E Pitting edema (+++), PRT < 40 sec, JVD (++) EF = 39%, Regional wall motion abnormality MV inflow pattern - restrictive pattern Imp) Heart Failure r/o restrictive cardiomyopathy Plan ) Diuretics Coronary angiography Cardiac MRI Cardiac biopsy

6. 입원 (2014.05.12)  2013.12 – 2014.05 : Dyspnea 호전  내원 5 일전부터 하루 3 회 이상의 watery diarrhea 지속되어 소화기내과 입원

7. 계통문진 General Febrile sensation(-) Chill(-) Fatigue(+) Headache(-) Edema (+) Skin Rash(-) Itching(-) Cardiac Chest Pain(-) Palpitations(-) syncope (-) Exertional dyspnea (+) Respiratory Cough(-) Sputum(-) Dyspnea(+) Hemoptysis (-) Gastrointestinal Anorexia(+) Nausea(+) Vomiting(+) Diarrhea(+) Abd. Distension (+) Genitourinary Flank pain(-) Dysuria(-) Urgency(-) Nervous Dizziness(-) Sensory loss(-) 하루 3 회이상 5 일 지속 5 개월간 Weight loss 10kg

8. 신체검진 Vital sign 100/60 mmHg – 78 /min – 20 /min – 36 ℃ Height : 158 cm Weight : 54.2 kg BMI : 21.7 kg/m 2 Abdomen Distended & Soft abdomen Td/rTd (-/-) Back&Ext. CVA Td (-/-) Pitting edema (+) Generalized edema (+)

9. Initial lab finding  CBC 14020 /uL – 12.5 g/dL – 39.1 % – 263,000 /uL (seg 56.8%) PT / INR 18.1 sec / 1.53 aPTT 41.3 sec  Chemistry TB/DB 3.39/2.53 mg/dL BUN/ Cr 20/0.7mg/dL Prot/ Alb 5.7 / 2.2 g/dL Ca/ P/ Mg 6.9/ 3.2 / 1.2 mg/dL ALP 188 IU/L Na /K /Cl 136 / 4.4 / 109 mEq/L AST/ALT 63 / 25 IU/L Uric acid 4.9 mg/dL CRP 0.91 mg/dL  Urine analysis pH 5.0S.G 1.021 Glucose - / uribilinogen 0.1 mg/dL / Ketone - / protein +++ RBC / WBC2~4/ 2~4

10. Chest X-ray

11. Initial EKG

12. Initial Problems #1. Fatigue #2. Weight loss (5 개월내 10 kg) #3. Anorexia #4. Dyspepsia #5. Diarrhea #6. Hyperbillirubinemia #7. Ascites #8. SMT #9. Dypnea #10. Pitting edema #11. JVD #12. Hypothyroidism #13. Proteinuria r/o malignancy r/o autoimmune disease r/o viral infection Tumor marker If needed image study Serologic screening HAV,HBV,HCV, CMV r/o Liver cirrhosis chronic diarrhea Billiary obstructive disease Image study EGD/CFS If needed ERCP HF (ICMP, HCMP,DCMP) CAG f/u Echo Cardiac MRI Subclinical hypothyroidism (TSH 5.16 -> 25)

13. Clinical course

14. 2014.05.12 adm Diarrhea Dyspne a 2014.05.13 EGD/CFS TTE

15. 2014.05.12 adm Diarrhea Dyspne a 2014.05.13 EGD/CFS TTE 2014.05.16 Duodenum Terminal ileum Stomach Biopsy 결과

16. 2014.05.12 adm Diarrhea Dyspne a 2014.05.13 EGD/CFS TTE 2014.05.16 Duodenum Terminal ileum Stomach Amyloidosi s 2014.05.21 BM

17. Other lab finding

18. Troponin I0.22 ng/mL BNP774 pg/mL TFT TSH 13.26 μ U/mL T3 <0.1ng/dL fT4 1.34 ng/dL Albumin2.2 g/dL ESR118 mm/hr Free light chain (Kappa)-Serum 53.3 (3.3 ~ 19.4) Free light chain (Lambda)-Serum 578 (5.71 ~ 26.3) Free light chain (Kappa&Lambda)- Serum 0.092 (0.26~ 1.65) Plasma cell - Bone marrow 37%

19. 2014.05.12 Adm 2014.05.132014.05.162014.05.21 BM EGD/CFS TTE Biopsy T/F Plasma Cell 37% Plasma Cell 37%

20. Final diagnosis Multiple myeloma + Systemic Amyloidosis