Case Conference 내분비대사 내과 R1 송 란
11754571 김준연 M/21 내원일 : 05.1.17 주소: 다음, 다뇨 시작일: 2004년7월 현병력: 평소 건강히 지내던 21세 남자환자 2004년 7월부터 수분 섭취량 증가하기 시작. 지속적으로 다음(8L/일), 다뇨(9L/일) 증상 있어 2005년 1월 동네 내과 의원 방문. 당뇨병 의심하여 검사 하였으나 당뇨병의 증거 보이지 않음. 요붕증 의심되어 본원 내분비대사내과로 전원. 과거력 : 고혈압(-), 당뇨(-), 결핵(-) 간염(-) 수술력(-), 외상(-), 약 복용력(-) 직업 : 군인 (2004년12월 부터 복무)
가족력 개인력 : 음주 (-) 흡연 (-) 당뇨병
Review of System General : fatigue(-) fever(-) chills(-) sweat(-) wt. Loss(+) : 77 kg68 kg (-9 kg / 7개월) Skin : rash(-) pigmentation(-) Itching(-) H/N : headache(-) trauma(-) stiiffness(-) Eye/ENT : sorethroat(-) dry mouth(+) visual disturbance(-) diplopia(-) hearing loss(-) Respiratory : cough(-) sputum(-) dyspnea(-) Cardiac : palpitation(-) chest discomfort(-) orthopnea(-) G.I. : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) Urinary : polyuria(+) : 8 L/day dysuria(-) nocturia(+) :2회/night frequency(+) : 12~15회/day Endocrine : polydipsia(+):9 L/day heat intolerance(-) Musculoskeletal: myalgia(-) cramps(-) weakness(-) numbness(-) Neurology : dizziness(-)
Physical Examination V/S : 120/70 mmHg-76회/min-20회/min-36.5°C General apperance alert conciousness not so ill appearance Skin no rash or pigmentation skin turgor : intact H/N normocephaly no neck vein engoregement no cervical LN enlargement no thyroid gland enlargement E/ENT isocoric pupil with PLR(+/+) pinkish conjunctiva clear sclera tongue : not dehydrated Pharyngeal injection(-) paratonsilar hypertrophy(+/+)
Thorax symmetric chest expansion clear breathing sound without rale regular heart beat without murmur Abdomen soft and flat abdomen normoactive bowel sound no hepatosplenomegaly no tenderness , no rebound tenderness Back / Extremity CVA tenderness(-/-) pretibial pitting edema(-/-) Neurologic Examination No visual disturbance Visual area :intact EOM :full Babinski sign(-/-) DTR(++/++) Motor :v/v/v/v sensory:intact
Impression Diabetes Insipidus r/o primary polydipsia
Diagnostic plan Serum electrolyte Urine specific gravity Basal serum & urine osmolality Serum antidiuretic hormone Water deprivation test Brain(sellar) MRI
Laboratory Finding CBC/DC 5520 mm3 -13.8 g/dL-39.6 %-231K (seg 48.0 %) INR :1.10 a-PTT : 43C33 Chemistry TB/DB 1.1/0.2 mg/dL AST/ALT 16/15 U/L ALP/GGT 44/11 U/L prot/alb 8.5/4.5 g/dL glucose 109 mg/dL BUN/Cr 7/0.9 mg/dL Na/K/Cl 138/3.6/102 mmol/L Uric acid 7.6mg mg/dL Ca/P/Mg 8.9/3.7/1.9 mg/dL UA RBC 0-1/HPF WBC 0-1/HPF Protein(-) Glucose(-) Ketone(-) SG: ≤ 1.005 pH: 5.5 Serum osmolality : 294 mosm/Kg Urine osmolality : 101 mosm/Kg
Chest X-ray
Water deprivation test (05.1.18) Basal (05.1.17) 9am. (05.1.18) 10am. 11am. MD 1pm. 2pm. Serum osmol. (mOSM/kg) 294 313 311 309 305 314 303 Urine osmol. 101 70 84 109 127 153 323 Body weight(kg) 68.6 68.8 67.6 67 66.7 66.4 66.1 Urine output(ml) 650 550 500 350 300 100 Pitressin 5u s.c. Basal ADH :1.1 pg/ml (NL:0.8~6.3 pg/ml) 1am. ADH :0.42 pg/ml (NL:0.8~6.3 pg/ml)
Pitressin 5u s.c
Brain (sella) MRI (05.1.19)
Triple test (05.1.19) Glu (S) (mg/dl) ACTH (P) (pg/ml) GH (S) (ng/ml) -30 min. 30 min. 60 min. 90 min. 120 min. Glu (S) (mg/dl) 92 38 53 54 56 ACTH (P) (pg/ml) 23.2 22.6 50.3 119.6 32.0 17.9 GH (S) (ng/ml) 0.8 3.7 1.6 15.7 8.6 5.0 Cortisol (S) (ug/ml) 18.0 14.4 18.9 25.2 24.9 25.9 FSH (S) (mIU/ml) 6.6 21.2 22.2 18.8 20.3 LH (S) (mIU/ml) 2.6 42.3 37.9 29.0 22.8 PRL (S) (ng/ml) 6.4 27.4 33.8 19.7 15.8 TSH (S) (-u/ml) 2.2 11.1 8.5 6.0 4.5 T3 : 161 ng/dl , FT4 : 1.48 ng/dl , TSH : 2.2 u/ml E2(S) : 0.1 pg/ml Progesterone(S) ? ng/ml Testosterone(S) : 3.84 ng/ml
Final diagnosis Severe Pituitary Diabetes Insipidus
Therapeutic plan Desmopressin Acetate (dDAVP) 0.05 mg bid p.o.
1/18 (water deprivation test) Clinical course 2005.1.19 저녁 dDAVP 0.05 mg p.o. Nocturia (-) Intake/Output 1/17, 4pm.~ (admission) 1/18 (water deprivation test) 1/19 (triple test) 1/20, ~9am. (discharge) Intake 4450 10050 2300 1700 Output 4250 9300 3900 1450 Serum osmolality : 287 mosm/Kg Urine osmolality : 302 mosm/Kg (1/20 아침 첫 소변)