Case conference Department of endocrinology and metabolism 2005 년 7 월 13 일

Patient information Chief complaint 오심을 동반한 전신무력감 ( 발병일 : 3 일전 ) Present illness 79 세 여자, 98 년 고혈압, 제 2 형 당뇨병으로 진단, 이후 내분비 내과 외래 추적관찰 도중 2 차례 비케톤성 고삼투압성 혼수로 입 원 치료 받은 과거력 있음. 1 개월전 저혈당 증상을 주소로 내원, 입원 치료후 nateglinide 90mg tid, acarbose 50mg tid 로 퇴원약 조절받아 퇴원 년 12 월 뇌경색으로 입원 치료 받은 과거력 있으나 실내 에서 거동 가능한 상태로 본원 신경과 다니면서 투약 병행하고 있었던 환자로 내원 3 일전부터 상기 주소 보이고 2 일전부터 전 신무력감 동반되어 누워 지내다가 외래 경유 입원 오재선 (F/79)

Past medical history 1. DM(+) for 7 years on medication (nateglinide 90mg tid, acarbose 50mg tid) 2. HTN(+) for 7 years on medication (irbesartan 150mg qd, thiazide 12.5mg qd, isosrbid mononitrate 60mg qd, aspirin 100mg qd) Pul. TB(-), Hepatitis(-) 3. CVA history(+) : 2002 년 12 월, 이후 NR OPD F/U 하며 medication 중. → 최근 (6 월 28 일 NR OPD 에서 citalopram 20mg qd 로 처방 추 가됨.) : d/t Rt. side hemibalismus ** Drug : fluvastatin 80mg qd (2003 년 6 월부터 )

Family history Unremarkable Personal history Alcohol(-), Smoking(-) 건강식품이나 기호식품 사용력 없음. Acute trauma or chronic immobilization history 없음.

Review of systems 1.General : generalized weakness (+), fatigue(+) fever/chilling sense(+/+) (2 days ago) 2.Skin : itching sense(-), easy bruisablitiy(-) 3.H & N : headache(-), neck stiffness(-), sore throat(+) 4.Breast : discharge(-), lump(-), pain(-) 5.Resp. : cough(-), sputum(-), dyspnea(-) 6.Cardiac : anginal chest pain(-), orthopnea(-), palpitations(-) 7.G-I : anorexia(+), nausea(+), vomiting(-) abdominal pain(-), constipation(-) 8.Urinary : dysuria(-), hematuria(-), incontinence(-) 9.M-S : generalized myalgia(+), trauma(-), joint pain(-) proximal muscle weakness(+) 10.Endo. : weight change(-), temperature tolerance(-) 11.Nerv. : syncope(-), seizure(-), memory disturbance(-)

Physical examination (V/S 120/80 mmHg-64 회 /min-20 회 /min-36.5 ℃ ) Body weight 59 kg/Height cm/BMI General appearance Alert consciousness Acutely ill-looking appearance 2.Skin No rash or pigmentation 3.Head & neck Normocephaly No neck vein engorgement No cervical lymph node enlargement 4. Eyes & ENT Isocoric pupil with PLR (+/+) No yellowish sclera, No pale conjunctiva

Physical examination 5. Chest Symmetric chest expansion Clear breathing sound without crackles or wheezing Regular heart beat without murmur 6. Abdomen Soft & flat abdomen Normoactive bowel sound No abdominal tenderness or rebound tenderness 7. Back & extremities No CVA tenderness or rebound tenderness No pretibial pitting edema 8. Neurologic signs No abnormal neurologic signs

Initial lab data 1.CBC/DC 6,710/mm 3 – 9.5g/dL – 27.7% - 179,000/mm 3 (Seg. 59.1%) 2.PT (%) INR : 12.7 sec (100%) aPTT : 32 C 33 4.Blood chemistry Total bil./Direct bil. 0.5/0.1 mg/dL Total cholesterol 134 mg/dL Protein/Albumin 6.3/3.6 g/dL AST/ALT 42/21 IU/L LD/CK 405/596 IU/L BUN/Creatinine 68/2.8 mg/dL (←35/1.9 mg/dL) Na/K/Cl 136/4.5/105 mmol/L 5. U/A : RBC 0~1/HPF, WBC 5~9/HPF

6.Spot urine chemistry Na/Cr 59 mmol/L/70 mg/dL ** FENa = 1.73 > 1 ** FEBUN = 37.4% (2002 년 12 월 24hrs urine CrCl 50.3 mL/min) 7. Myoglobin 519 ng/mL Urinary myoglobin (+) 8. HbA1c 6.7%

Impression Rhabdomyolysis R/O drug-induced rhabdomyolysis Acute on chronic kidney disease d/t rhabdomyolysis Asymptomatic pyuria in type 2 DM patient Plan Hydration and causative medication stop Urine culture and antibiotics

F/U lab data(HD 4 일 ) 1. Blood chemistry BUN/Creatinine 20/1.9 mg/dL Na/K/Cl 140/4.3/114 mmol/L Myoglobin 84.7 ng/mL 2. U/A : RBC 2~4/HPF, WBC 5~9/HPF Many bacteria 3. Urine culture : less than 1,000 CFU/mL

Final diagnosis 1.R/O drug-induced rhabdomyolysis 2.Acute on chronic kidney disease d/t rhabdomyolysis 3.Asymptomatic pyuria and bacteriuria 4.Type 2 diabetes mellitus 5.Hypertension 6.Old cerebral infarction