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1 Case conference Endocrinology R1 임효석. 2 11853316 한 O 석 F/72 admission 06-8-20 C.C) uncontrolled DM P.I)  3 년 전 type 2 DM 진단 받은 후 개인 병원에서 경구 혈당 강하제.

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Presentation on theme: "1 Case conference Endocrinology R1 임효석. 2 11853316 한 O 석 F/72 admission 06-8-20 C.C) uncontrolled DM P.I)  3 년 전 type 2 DM 진단 받은 후 개인 병원에서 경구 혈당 강하제."— Presentation transcript:

1 1 Case conference Endocrinology R1 임효석

2 2 11853316 한 O 석 F/72 admission 06-8-20 C.C) uncontrolled DM P.I)  3 년 전 type 2 DM 진단 받은 후 개인 병원에서 경구 혈당 강하제 (Glimepride, Voglibose) 로 조절  내원 2 주전 오른쪽 얼굴에 대상포진 발생하여 Methylprednisolone 포함한 약을 복용 후 혈당 조절 되지 않아 혈당 조절 및 당뇨 합병증 검사 위해 입원.

3 3 PMHx) DM/HTN/pul.Tb/hepatitis(+/-/-/-) DM : Glimepride 3mg, Voglibose 0.3mg Osteoarthritis (+) Old L-spine (L5) compression Fx. OP.Hx(+) : Cataract op. both - 2 년 전 Drug Hx : Phenytoin, Amitriptyline, hydroxyzine Cimetidine, Gabapetine  일주일 간 복용 FHx.) None PHx.) Alcohol(-) Smoking(-)

4 4 Review of system  General fatigue(+) wt. Loss(+) (70  54kg for 3yrs) fever(-) chills(-)  Skin rash with crust formation(+) -Rt. face  H/N headache(-) stiffness(-)  Resp. cough(-) sputum(-) dyspnea(-)  Cardiac chest pain(-) orthopnea(-) palpitation(-)  G.I A/N/V/D/C(+/-/-/-/-) abdomial pain(-)  Nervous syncope(+) : 내원 4 일 전 5 분간 LOC (+) seizure(-) dizziness(-) tremor(-)  Musculoskeletal muscle cramp(-) paralysis(-)

5 5 Physical examination V/S 150/90 mmHg-104 회 /min-20 회 /min-36°C Bwt. 58.0Kg Ht. 155cm BMI 23.2Kg/m²  G/A alert conciousness chronically ill looking appearance  Skin rash with crust formation – Rt. face no pigmentation normal skin turgor  H/N no thyroid gland enlargement no neck vein engorgement  E/ENT isocoric pupil with PLR(+/+) Pharyngeal Injection(-) PTH(-/-)

6 6 Physical examination  Thorax clear breathing sound without rale regular heart beat without murmur  Abd. soft & flat abdomen normoactive bowel sounds no hepatosplenomegaly tenderness/rebound tenderness(-/-)  B/EXT CVA tenderness(-/-) pretibial pitting edema(-/-)  Neurology motor, sensory - intact

7 7 Laboratory finding CBC/DC 4390/mm² -11.7 g/dl-32.4 %-71K (seg 67.1%) Chemistry TB/DB 1.23/0.56 mg/dl AST/ALT 137/143 U/L ALP/GGT 67/334 U/L Prot./alb 5.3/2.3 g/dl LD/CK 533/74 U/L BUN/Cr 7/0.7 mg/dl Ca/Mg/P/uric acid 7.6/1.9/2.1/2.5 mg/dl Glucose 342 mg/dl Na/K /Cl 133/2.7/103 mmol/l UA RBC 2-4/HPF WBC 10-29/HPF Osmolality serum/urine 286/311 mOSM/Kg Spot urine Na/K/Cl 35/4/36 mmol/l Cr 16 mg/dl

8 8 Laboratory finding  Anti-HAV IgM : Negative  HBsAg : Negative  HBcAb : Positive  HBsAb : Positive  Anti-HCV : Positive

9 9 ECG

10 10 Chest PA

11 11 Impression 1. Type 2 DM 2. Chronic hepatitis C 3. Syncope R/O Hypoglycemia R/O Transient ischemic attack 4. Primary hyperaldosteronism 5. Old L-spine(L5) compression fracture 6. Asymptomatic pyuria

12 12 Diagnostic & Therapeutic plan 1. Type 2 DM C-peptide C-peptide DM complication study DM complication study Multiple daily injection Lantus 12U Multiple daily injection Lantus 12U Humalog 10U/10U/10U Humalog 10U/10U/10U 2. Chronic hepatitis C HCV RT-PCR HCV RT-PCR Abdominal sono Abdominal sono 3. Syncope Brain MRI with diffusion scan Brain MRI with diffusion scan

13 13 Diagnostic & Therapeutic plan 4. Primary hyperaldosteronism Lasix 복용 유무 확인 Plasma renin activity Serum Aldosterone Saline loading test or Lasix stimulation test

14 14 Diagnostic & Therapeutic plan 5. Old L-spine(L5) compression fracture L-spine AP / Lateral BMD(Bone mineral density) 6. Asymptomatic pyuria U/A F/U Urine culture

15 15 Lasix stimulation test (06-9-4)  06:00 Lasix 2A(40mg) IV 후 서서 다님  06:55 Severe dizziness, Palpitation, Sweating 발생 Systolic BP : 40 mmHg GMT 135 mg/dL  Bed rest & Normal saline loading  07:00 BP 110/70 mmHg HR 90/min dizziness 증상 호전

16 16 Brain MRA c Diffusion (06.9.6)

17 17 Pituitary function test GHFSHLH 26.3 ng/ml92.9 mIU/ml36.4 mIU/ml T3FT4TSH 136 ng/dL1.14 ng/dL8.28 mU/L ACTHCortisol 23.9 pg/mL/10.9 pg/mL16.9 ug/dl 8.0 ug/dl 9 to 52 pg/ml 6 to 23 mcg/dl 0 to 3 ng/ml 25.8-134.8 IU/L 5 to 20 IU/L

18 18 KCL 40 mEq/d IV Clinical Course Lasix stimulation test 40mg IV Syncope (SBP 40mmHg) KCL 4g PO 9/6 : Aldactone 25mg bid 9/7 : Aldactone 25mg bid 9/8 : Aldactone 50mg / 25mg 9/9 : Aldactone 50 mg bid (2.7) (3.1) (3.9) (2.8) (3.9) (3.3) (3.5) (3.1) (4.1)

19 19 Lasix stimulation test (06-9-4) Basal2hrs later Aldosrerone(ng/dl)2.239 PRA(ng/ml/hr)0.22.0 Aldosterone/PRA ratio 10 14.5 (ng/dl per ng/ml/hr)

20 20 1. Type 2 DM Humalog 28U / 28U + Metformin 500mg b.i.d 2. Chronic hepatitis C Abdominal Sonogram : Mild fatty liver HCV RT-PCR : Positive  환자 나이 72 세로 IFN 이나 Ribavirin 은 사용하지 않음

21 21 OPD F/U (06.9.18) NaKCl 1244.298 단위 : mmol/L ★ 10 월 6 일 Brain MRI F/U 예정

22 22 SELLA MRI


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