Problem Case 순환기 내과 R1 최소영

김 O 주 F/29 내원일 :2005 년 5 월 26 일 CC: Feveronset) 3 days ago CC: Feveronset) 3 days ago PI : F/29, 5 년전 첫아기 임신 8 개월째에 발병한 농포성 건선으로 입원 치료 받았으며, 이후 악화와 호전 반복하 던 중 4 개월 전인 임신 6 개월째 재발하여 topical agent 로 치료 후 완화되었다가 분만 후 (8 일전 ) 다시 재발되어 피부과 외래 f/u 하던 중 3 일전부터 발열, 기침 있으면서 피부 병변 악화되는 양상보여 본원 피부과에 입원함 PI : F/29, 5 년전 첫아기 임신 8 개월째에 발병한 농포성 건선으로 입원 치료 받았으며, 이후 악화와 호전 반복하 던 중 4 개월 전인 임신 6 개월째 재발하여 topical agent 로 치료 후 완화되었다가 분만 후 (8 일전 ) 다시 재발되어 피부과 외래 f/u 하던 중 3 일전부터 발열, 기침 있으면서 피부 병변 악화되는 양상보여 본원 피부과에 입원함 PMHxHTN / DM / TB / HEPATITIS (-/-/-/-) PMHxHTN / DM / TB / HEPATITIS (-/-/-/-) OP Hx (-) FMHxNone FMHxNone PHx Smoking (-) Alcohol (-) PHx Smoking (-) Alcohol (-)

Review of System General : fever(+)chills(+) sweat(-) General : fever(+)chills(+) sweat(-) Skin : generalized desquamation (+) pustule (+) Skin : generalized desquamation (+) pustule (+) Head & Neck : headache(-) trauma(-) stiiffness(-) Head & Neck : headache(-) trauma(-) stiiffness(-) Eye & ENT : sore throat(-) hoarseness(-) Eye & ENT : sore throat(-) hoarseness(-) Respiratory : cough(+) sputum(-) dyspnea(-) Respiratory : cough(+) sputum(-) dyspnea(-) Cardiac : palpitation(-) chest discomfort(-) Cardiac : palpitation(-) chest discomfort(-) Gastrointestinal : A/N/V/D/C(+/-/-/-/-) abdomial pain(-) Gastrointestinal : A/N/V/D/C(+/-/-/-/-) abdomial pain(-) Urinary : dysuria(-) nocturia(-) frequency(-) Urinary : dysuria(-) nocturia(-) frequency(-) Endocrine : polydipsia(-) heat intolerance(-) Endocrine : polydipsia(-) heat intolerance(-) Musculoskeletal : myalgia(-) weakness(-) back pain(-) Musculoskeletal : myalgia(-) weakness(-) back pain(-)

Physical Examination V/S 120/70 mmHg - 76 회 /min - 20 회 /min °C V/S 120/70 mmHg - 76 회 /min - 20 회 /min °C Height 155cm Body weight 56.8kg BMI 23kg/m 2 Height 155cm Body weight 56.8kg BMI 23kg/m 2 General apperance General apperance Alert conciousness Alert conciousness Acute ill appearance Acute ill appearance Skin Skin Intact skin turgor Intact skin turgor Generalized desquamation (+)pustule (+) Generalized desquamation (+)pustule (+) Generalized erosion (+)patches (+) Generalized erosion (+)patches (+) Head & Neck Head & Neck No neck vein engorgement No neck vein engorgement No cervical LN enlargement No cervical LN enlargement No thyroid gland enlargement No thyroid gland enlargement

Eye & ENT Eye & ENT Isocoric pupil with PLR(++/++) Isocoric pupil with PLR(++/++) Pinkish conjunctiva Clear sclera Pinkish conjunctiva Clear sclera Pharyngeal injection(-) Peritonsilar hypertrophy(+/+) Pharyngeal injection(-) Peritonsilar hypertrophy(+/+) Thorax Thorax Symmetric chest expansion Symmetric chest expansion Clear breathing sound without rale Clear breathing sound without rale Regular heart beat without murmur Regular heart beat without murmur Abdomen Abdomen Soft and flat abdomen Soft and flat abdomen Normoactive bowel sound Normoactive bowel sound No tenderness, No rebound tenderness No tenderness, No rebound tenderness Back / Extremity Back / Extremity CVA tenderness - not checked CVA tenderness - not checked Pretibial pitting edema(-/-) Pretibial pitting edema(-/-)

Laboratory Finding ( ) CBC/DC16200/mm 3 – 11.9g/dL-34.8 %-346k/mm 3 (88.1%) (MCV 87.9 fl MCH 34.2 g/dl) CBC/DC16200/mm 3 – 11.9g/dL-34.8 %-346k/mm 3 (88.1%) (MCV 87.9 fl MCH 34.2 g/dl) Chemistry Chemistry AST/ALT 34 / 51 IU/ ALP/GGT 218 / 76 IU/L AST/ALT 34 / 51 IU/ ALP/GGT 218 / 76 IU/L Glucose 117 mg/dL BUN/Cr 11 / 0.9 mg/dL Glucose 117 mg/dL BUN/Cr 11 / 0.9 mg/dL Na/K/Cl 140 / 4.1 / 102 mmol/L Na/K/Cl 140 / 4.1 / 102 mmol/L UA RBC 10-29/HPF WBC 10-29/HPF UA RBC 10-29/HPF WBC 10-29/HPF Leukocyte ++nitrate -prot+- Leukocyte ++nitrate -prot+- (5.24 UA RBC 2-4/HPFWBC many ) (5.24 UA RBC 2-4/HPFWBC many )

EKG ( )

Chest X-ray ( )

Initial problem list Fever with Pyuria Fever with Pyuria Cough Cough Anemia Anemia Abnormal liver test Abnormal liver test Generalized pustulopsoriasis Generalized pustulopsoriasis

Intial assessment APN APN Anemia d/t postpartum bleeding Anemia d/t postpartum bleeding cholestatic hepatitis cholestatic hepatitis Known generalized pustulopsoriasis Known generalized pustulopsoriasis

Intial diagnostic & therapeutic plan Fever study  antibiotics Fever study  antibiotics  UA, Urine culture f/u  UA, Urine culture f/u Liver test f/u, if needed, abd. sono Liver test f/u, if needed, abd. sono Discontinue causative drug Discontinue causative drug Methotrexate 2.5mg qd  dose escalation Methotrexate 2.5mg qd  dose escalation dressing, symptomatic management dressing, symptomatic management

Clinical coarse ( ) Generalized edema 발생 Generalized edema 발생 V/S : 120/70 mmHg 회 /min - 20 회 /min °C V/S : 120/70 mmHg 회 /min - 20 회 /min °C CBC/DC7370/mm3 – 10.2g/dL-30.3 %-253k/mm3 (87.6%) CBC/DC7370/mm3 – 10.2g/dL-30.3 %-253k/mm3 (87.6%) Chemistry Chemistry TB/DB 2.0/1.4 mg/dL AST/ALT 17/25 IU/L ALP/GGT 180/67 IU/L Prot/Alb 4.1/1.7 g/dL Glucose 109 mg/Dl Na/K/Cl 140/4.0/106mmol/L BUN/Cr 8/0.8 mg/dL CRP 16.9 BUN/Cr 8/0.8 mg/dL CRP 16.9 Ca/P 7.9/2.6 mg/dL Chest PA : pul. congestion Chest PA : pul. congestion UA) RBC WBC UA) RBC WBC UC) 시행 UC) 시행 Albumin, Lasix Cefazolin, ciprofloxacin (250mg tid) MTX 5mg 증량

Clinical coarse (05.6.1) UCno growth UCno growth Bronchiolitis impression 하에 clarithromycin 1 주간 사용 Bronchiolitis impression 하에 clarithromycin 1 주간 사용 6.6 까지 38 °C 이상의 fever 6.6 까지 38 °C 이상의 fever 부터 37~37.9°C

Clinical coarse (05-6-7) Dyspnea 발생, decreased urine output (I/O 2200 / 700) Dyspnea 발생, decreased urine output (I/O 2200 / 700) ICU 로 옮김 ICU 로 옮김 V/S 80/60 mmHg 회 /min - 30 회 /min °C V/S 80/60 mmHg 회 /min - 30 회 /min °C ABGA ABGA mmHg mmHg mmol/L-97.1% Lactic acid mmol/LAG34mEq/L Heart enzymeLD/CK/CK-MB16210/83/1.7 (U/L) Heart enzymeLD/CK/CK-MB16210/83/1.7 (U/L) TnI / Myoglobin 0.13 / 132 (ng/ml) Chest PAPulmonary edema Chest PAPulmonary edema EKGSinus tachycardia EKGSinus tachycardia BNP1274 pg/ml BNP1274 pg/ml CBC11980/mm %-287k (87.9%) CBC11980/mm %-287k (87.9%) PT/PTT37.9 s (INR 3.84) / 51 C 33 FDP>20 mg/mlFibrinogen338 mg/dl FDP>20 mg/mlFibrinogen338 mg/dl D-dimer8.14

Clinical coarse (05-6-7) Chemistry Chemistry TB/DB 2.7 / 1.9 mg/dL AST/ALT 462 / 75 IU/L ALP/GGT 157 / 56 IU/L Prot/Alb 5.4 / 2.2 g/dL Glucose 109 mg/dL BUN/Cr 85/4.1 mg/dL Na/K/C 139/5.9/109mmol/L BUN/Cr 85/4.1 mg/dL Na/K/C 139/5.9/109mmol/L FENa 0.8 FENa 0.8 Blood,Urine culture No growth IN Transfer CRRT Color D E Abdominal sono

Abdominal US(05-6-8)

Echocardiography(05-6-8)

Clinical course CRRT 시행 (05-6-7~6-10) CRRT 시행 (05-6-7~6-10) °C 이상의 fever-- Levofloxacin 사용 fever subcide 됨 °C 이상의 fever-- Levofloxacin 사용 fever subcide 됨 임상양상,lab 호전되어 일반병실로 옮김 임상양상,lab 호전되어 일반병실로 옮김 f/u Color D E 시행 f/u Color D E 시행 blood Cx (1/3) VRE blood Cx (1/3) VRE Urine Cx VRE (6-13 시행 ) Urine Cx VRE (6-13 시행 ) -- Linezolid 사용함 -- Linezolid 사용함 퇴원함 퇴원함

Echocardiography( )

Diagnosis Diagnosis Reversible cardiomyopathy Reversible cardiomyopathy Takotsubo cardiomyopathy Peripartum cardiomyopathy Septic shock Septic shock ARF with lactic acidosis ARF with lactic acidosis