Problem case 내분비 대사 내과 R2 문수연

CC) amenorrhea and galactorrhea onset) 27 months ago 11754374 김O란(F/35) CC) amenorrhea and galactorrhea onset) 27 months ago PI) 처녀 때부터 oligomenorrhea 있던 35세 여자 환자로 배란 유도를 통해 자녀 2명을 출산 하였으며, 27개월 전 둘째 아이 출산 후 amenorrhea와 galactorrhea 있어 산부인과 방문, 산부인과적 문제 없다 듣고 타 병원에서 측정한 prolactin 47.8 ng/mL 소견 보여 본원 내과 외래 방문함. 내원 3 주 전부터 개인 의원에서 체중 감량 위해 약 복용 중이었음. PMHx) DM(-) HTN(-) TB(-) hepatitis(-) Op Hx(+) c/sec 2 회 PHx) Alcohol(-) Smoking(-)

Drug history) 디바 1T tid thiamine 20 mg bid fluoxetine 10 mg bid pyridoxine 2 mg bid diazepam 2 mg qd pseudoephedrine 0.5 mg tid FHx)

Review of systems General: fever(-) chill(-) fatigue(+) Skin: rash(-) pigmentation(-) Head and neck: headache(-) neck stiffness(-) Respiratory: dyspnea(-) cough(-) sputum(-) Cardiac: palpitation(-) chest pain(-) orthopnea(-) GI: abdominal pain(-) A/N/V/D/C(-/-/-/-/-) Urinary: frequency(-) dysuria(-) urgency(-) Reproductive: amenorrhea(+) galactorrhea(+) Endocrine: hair loss(-) weight gain(+)

Physical examination V/S 130/70 mmHg – 84/min – 20/min – 36.5℃ Body weight: 63 ㎏ height: 162 ㎝ BMI: 24 ㎏/㎡ General Alert consciousness Not so ill-looking appearance Skin No rash/pigmentation Head and neck No cervical LN enlargement No thyroid enlargement No neck v. engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Pinkish conjunctiva Clear sclera PI(-) PTH(-)

Chest Symmetric chest expansion Clear breath sound without crackle/wheezing Regular heart beat without murmur Galactorrhea(+) both, squeezing Abdomen Soft and obese Normoactive bowel sound No tenderness/rebound tenderness Back and extremity CVA tenderness(-/-) Pretibial pitting edema(-/-) Neurology Motor V V Sensory: intact V V Babinski(-/-)

Impression Prolactinoma r/o Drug-induced hyperprolactinemia r/o Nonfunctioning pituitary tumor compressing pituitary stalk r/o Pleurihormonal adenoma

Plan hCG BUN/Cr TFT Prolactin level (Combined pituitary stimulation test) Sella MRI, if needed

Lab findings CBC/DC 4030/mm3 – 12.0 g/dL/ 36.6 % - 319000/mm3 (seg. 53 %) Chemistry TB/DB 0.7/0.2 mg/dL Glucose 95 mg/dL AST/ALT 11/19 U/L BUN/Cr 11/0.7 mg/dL ALP 60 U/L Na/K/Cl 142/3.8/108 mmol/L Prot/Alb 6.2/3.9 g/dL T-chol 211 mg/dL TFT TSH 1.90 μU/mL T3 171 ng/dL free T4 1.18 ng/dL

Combined pituitary stimulation test -30 min 0 min 30 min 60 min 90 min 120 min Glucose (mg/dL) 94 40 63 62 84 ACTH (pg/mL) 29.1 24.8 357.8 243.8 181.1 71.1 Cortisol (μg/dL) 16.2 10.4 19.9 29.0 32.8 34.7 GH (ng/mL) 0.06 12.3 14.2 34.1 22.2 FSH (mIU/mL) 5.3 20.9 20.2 19.5 18.4 LH (mIU/mL) 5.0 106.5 74.8 61.8 44.5 PRL (ng/mL) 31.1 39.5 32.3 33.8 TSH (μU/mL) 2.6 24.7 14.9 10.5 6.9

MRI

Diagnosis Idiopathic hyperprolactinemia r/o Microprolactinoma

Clinical course Bromocryptine 1.25 mg bid Bromocryptine 1.25 mg qd 2005-01-11 2005-01-21 2005-02-15 2005-01-25 2005-03-09 2005-03-13 Bromocryptine 1.25 mg qd 2005-03-17 Bromocryptine 1.25 mg bid