Case conference. TAKUGA HINOSHITA 2 nd resident ONMC

Transcription

1 Case conference TAKUGA HINOSHITA 2 nd resident ONMC

2 38 y/o female, Japanese CC: Dyspnea, Muscle clump, Numbness

3 HPI Since 1 week PTA, she s been complaining of fever around 38, chills, cold sweat and nocturnal dyspnea. 2 ~ 3 days PTA, she started to have numbness and Pngling at both of her lower extremipes, which gradually spread to her whole body. on admission day, because weird sensapon, muscle clump, SOB, and orthopnea were begun during sleeping, she was admised to ER by ambulance. She also complained of slight hair loss, rhinorrhea, hot flushing, palpitapon, and nausea. There were no headache and diarrhea.

4 # HTN: since high school, 180/130 mmhg # PyronephriPs: 14 years ago # Pneumonia: 8 years ago # Asthma: 4 years ago # Hypocalcemia: 3 years ago, hospitalized Heart/Liver/Diabetes/Thyroid/Parathyroid φ Hx of surgical operapon φ MedicaPon φ, NKDA PMH/FHx/SHx Para 0000, 1 st period 14 y/o, 2 3/year, quite heavy Father: HTN, anemia Aunt: asthma Smoke: 1PPD 20years, currently 1~2 pieces/d ETOH: cocktail 500ml 4~5/d = 2000~2500ml/d (120~150g) Diet: light, unbalanced, water 2L/d instead Married, Caring for her parents everyday No helper, Private Pme restricted

5 General Dermatological Head Eyes Ears Nose Mouth & Throat Neck Cardiovascular Respiratory Breast GastrointesPnal Renal & Urological Endocrine Musculoskeletal & Ext. ReproducPve Neurological Behavioral & Psychiatric System review

6 PEx BP 180/100mmHg, HR 116/min, RR 36/min, SpO2(RA) 96%, BT 37.2 H 149 cm, W 47kg, BMI 21.2 GCS 15pts, alert, General slightly sick HEENT: PERRLA, pale conjuncpva (+), icteric(-), fundus micro hemorrhage (+), rhinorrhea(+), wet mouth, tongue not swollen/shrunk, lip cyanosis(-), CLN/ SCLN(-), JVD(+), goiter(-), pharynx not reddish, tonsil not swollen Heart: regular, S1( )S2( )S3(+)S4(+) Lung: wheeze(-), crackle(+)@right side chest Abd: son, flat, tenderness(-), mass(-), hepatosplenomegaly(-) Back: CVA tenderness(-) Ext: warm, edema(-), asterixis(-), clubbing(-), Trousseau sign(+) Skin: rash(-), tasoo(+) MMT: b/l 5/5 DTR: systemically hyperreflex (3+), Babinski(-) CNS: n.p. Sensory/VibraPon: n.p.

7 PEx BP 180/100mmHg, HR 116/min, RR 36/min, SpO2(RA) 96%, BT 37.2 H 149 cm, W 47kg, BMI 21.2 GCS 15pts, alert, General slightly sick HEENT: PERRLA, pale conjuncpva (+), icteric(-), fundus micro hemorrhage (+), rhinorrhea(+), wet mouth, tongue not swollen/shrunk, lip cyanosis(-), CLN/ SCLN(-), JVD(+), goiter(-), pharynx not reddish, tonsil not swollen Heart: regular, S1( )S2( )S3(+)S4(+) Lung: wheeze(-), crackle(+)@right side chest Abd: son, flat, tenderness(-), mass(-), hepatosplenomegaly(-) Back: CVA tenderness(-) Ext: warm, edema(-), asterixis(-), clubbing(-), Trousseau sign(+) Skin: rash(-), tasoo(+) MMT: b/l 5/5 DTR: systemically hyperreflex (3+), Babinski(-) CNS: n.p. Sensory/VibraPon: n.p.

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9 CBC : WBC 6,700/μL Hb 6.9g/dl, Hct 22.6%, MCV 68fL, Ret 12 PLT 229,000/uL Labo data Chemi : Na 144mEq/L, K 3.1mEq/L, Cl 106mEq/L, Ca 6.4mg/dl, Mg 1.0mg/dl, IP 2.7mg/dl BUN 7mg/dl, Cre 0.5 mg/dl, GOT 78 IU/L, GPT 26 IU/L, ALP 293 IU/L LDH 349 IU/L, T- Bil 0.8mg/dl, BS 106mg/dl, CPK 176 IU/L, CK- MB 7 IU/L TSH μu/ml, vit.b12 173pg/mL, TP 6.5 g/dl, Alb 3.6 g/dl Fe 41 μg/dl, TIBC 449 μg/dl, FerriPn <3 ng/ml ABG (ambient air) : ph 7.503, pco mmhg, po mmhg, HCO mmol/l UA : U Osm 1.013, ph 7.5, protein (-), occult blood (-) U- Na 224 meq/l, U- K 9.3 meq/l, U- Cl 173 meq/l, U- Ca 6.8 mg/dl

10 CBC : WBC 6,700/μL Hb 6.9g/dl, Hct 22.6%, MCV 68fL, Ret 12 PLT 229,000/uL Labo data Chemi : Na 144mEq/L, K 3.1mEq/L, Cl 106mEq/L, Ca 6.4mg/dl, Mg 1.0mg/dl, IP 2.7mg/dl BUN 7mg/dl, Cre 0.5 mg/dl, GOT 78 IU/L, GPT 26 IU/L, ALP 293 IU/L LDH 349 IU/L, T- Bil 0.8mg/dl, BS 106mg/dl, CPK 176 IU/L, CK- MB 7 IU/L TSH μu/ml, vit.b12 173pg/mL, TP 6.5 g/dl, Alb 3.6 g/dl Fe 41 μg/dl, TIBC 449 μg/dl, FerriPn <3 ng/ml ABG (ambient air) : ph 7.503, pco mmhg, po mmhg, HCO mmol/l UA : U Osm 1.013, ph 7.5, protein (-), occult blood (-) U- Na 224 meq/l, U- K 9.3 meq/l, U- Cl 173 meq/l, U- Ca 6.8 mg/dl

11 Labo data Na 144 meq/l CPK 176 IU/L Fe 41 μg/dl ph K 3.1 meq/l CK- MB 7 IU/L TIBC 449 μg/dl pco mmhg Cl 106 meq/l WBC 6,700 /μl UIBC 408 μg/dl po mmhg Ca 6.4 mg/dl RBC 3,330,000 /μl Ret 12 K+ 2.7 mmol/l Mg 1.0 mg/dl Hb 6.9 g/dl FerriPn <3 ng/ml Ca mmol/l IP 2.7 mg/dl Ht 22.6 % A/G 1.2 HCO mmol/l BUN 7 mg/dl MCV 68 fl BNP pg/ml U Osm Cre 0.5 mg/dl MCH 20.8 pg int- PTH 54 pg/ml U ph 7.5 GOT 78 IU/L MCHC 30.8 % vit.d 54.7 pg/ml U- Na 224 meq/l GPT 26 IU/L PLT 229,000 /ul U- K 9.3 meq/l ALP 293 IU/L Free T pg/ml U- Cl 173 meq/l LDH 349 IU/L Free T ng/ml Vit.B1 42 ng/ml U- Ca 6.8 mg/dl T- Bil 0.8 mg/dl TP 6.5 g/dl Vit.B pg/ml U- IP 50.5 mg/dl BS 106 mg/dl Alb 3.6 g/dl Folate 8.5 ng/ml U- Mg 13.0 mg/dl

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14 ohters Echocardiogram : diffuse hypokainesis of the LV wall, diffuse wall thickning, no valvular Dx CT : almost normal findings

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16 Problem list Dyspnea Night sweat Muscle clump Numbness Vomit URI symptom(+) HTN SpO2 CHF Anemia Respiratory acidosis Metabolic alkalosis K/Ca/Mg LFTs BNP Alcohol smoke Dismennorhea Short stature?

17 # HF # Anemia # HTN # Lytes # Alcoholism # Myoma/ dysmenorrhea # Muscle clump/ Numbness

18 Heart Failure d/t HTN, Anemia, Alcohol, NaCl intake? Len Ventricular hypokinesis 1 st :cardiomyopathy(hcm,dcm)? 2 nd :ETOH,Collagen,Amyloidosis, BeriBeri,IHD? vit B1 normal, ANA etc are negapve

19 Anemia Fe, ferripn IDA s/o d/t myoma vit.b12 vit.b12 defeciency, macrocytosis is combined? d/t alcoholism? Atrophic gastrips? Intrinsic factor deficiency? gastroscope showed the normal findings. likely to have Chronic GI tract bleeding, hemorrhoid, menstrapon defect malnutripon, malabsorppon syndrome, others

20 HTN 1 st : familial, environmental, NaCl++, 2 nd : renovascular, Aldsteronism?, Pheochromocytoma? Abd.echo & CT r/o adrenal tumor and renovascular stenosis negapve findings Renin acpbity / aldosteron, catecholamines nomal range

21 Electrolytes Mg Ca/K d/t alcoholism vomit, diurepc, purge, vit.d, Aldsteronism, parathyroid hormone Gitelman synd?, Barter synd?, Liddle synd? PTH normal, vit D normal Renin/ald normal

22 Muscle clump/ Numbness Muscle clump : Ca, Neuro- muscular Dx(vitB1, vitb12, Alcohol ), K, others Numbness : Ca, Neuro- muscular Dx(vitB1, vitb12,folate Alcohol ), K, others vit.b1 and folate is normal

23 CHF ETOH HTN What is cause? Malnutri>on B12 Lyte Mg K Ca Anemia d/t IDA myoma Muscle clump and numbness

24 Conclusion?? # Hypertensive heart? # Electrolytes deficit d/t alcohol # Hypertension There is no apparent 2 nd HTN, hormonal nor renovascular. # vit.b12

25 Fin.