CASE presentation 신장내과 R1 박상준

Patient identification Hospital No. : 1771490 Name : 김 O 선 Age / Sex : 26/F Admission date : 2013.02.21

Chief complaints Dypsnea Onset) 내원 당일 저녁 8시경 By) Spontaneously

Present illness 26세 여자환자, 내과적 특이 과거력 없는 환자로 내원 2일 전 heartburn으로 local 병원 내원하여 감기약, 식도염 약 처방받아 복용하였고, 금일 저녁 8시경 dyspnea 호소하여 성애병원 내원, 갑작스런 의식저하로 intubation 하였고, BUN/Cr 의 상승 및 electrolyte imbalance로 ICU 및 CRRT 위해 본원으로 전원 26세 여자 내과적 특이 과거력 無 감기약, 식도염약 복용 – H2 blocker, cough syrup dyspnea 갑작스런 의식저하 BUN/Cr 의 상승 및 electrolyte imbalance 방문하였고, BM biopsy 상 t(9;22)(q34;q11.2) CML chronic phase 진단 후 치료 위해 본원 내원함.

Past history DM (-) / Hypertension (-) Tuberculosis (-) Hepatitis(-) Social History Alcohol drinking : none Cigarette smoking : none Familial Hx. -父 : 뇌출혈 / 母, 妹: 고혈압 Hospitalization/Operation History 1년 전 쌍커풀 수술받음

Review of system Abdomen General Genitourinary tract Chest Abd discomfort(-) Anorexia (-) Nausea (-) Vomiting (-) Diarrhea (-) Constipation (-) Genitourinary tract Dysuria (-) Hematuria (-) Frequency(-) Back & Extremities Back pain (-) Tingling sensation (-) General General weakness (-)/Fatigue (-) Myalgia (-) Fever (-) Chill (-) Dizziness (-) Wt.change (-) Chest Cough (+) Sputum (-) Chest pain (+) Dyspnea (+) 본원 내원당시에는 intubation state

Physical examination Vital sign General appearance HEENT & Neck BP : 150/100 mmHg BT : 36.9℃ PR : 90회/min RR : 16 회/min General appearance Acute ill looking appearance with stupor mental status HEENT & Neck Pale conjunctiva(-) Icteric sclera(-) Throat injecti Dehydrated tongue(-) Gingival bleeding (-)

Physical examination Chest Abdomen Back & Extremities Symmetrical chest expansion Both lung coarse breathing sound with LLL rale Abdomen Soft & Flat Normoaudible bowel sound Tenderness/Rebound tenderness(-/-) Hepatomegaly (-) Splenomegaly (-) Back & Extremities Pretibial pitting edema(-/-) Back Tenderness (-)

Diagnostic plan # R/O AKI - CBC, chemistry, electrolyte # R/O hypertensive CVA - Brain CT # HTN

Lab findings 검사 항목 결과 WBC 31300 Hb/Hct 9.9/29.4 PLT 99K BUN/Cr [eGFR] 37/5.29 [10.4] Na / K / Cl 125/2.5/79 Creatinine , Random urine 23.77mg/dL Sodium , Random urine 89mmol/L FENa 15.8 Osmolarity, Plasma 270mOsm/kgH2O 269mOsm/kgH2O Potassium, Random urine 24.9mmol/L TTKG 9.99

Chest X-ray(AP)

Problem list & Plan # AKI # Pulmonary edema : CRRT & BUN/Cr , CXR f/u # Electrolyte imbalance - Hypokalemia / Hyponatremia : electrolyte f/u, FENa, TTKG # HTN

Medication High dose estrogen Adrenal steroids Decongestant Appetite suppresants Cyclosporin TCA MAO inhibitor EPO NSAID cocaine

Neurogenic Psychogenic Diencephalic syndrome Familial dysautonomia Polyneuritis Acute IICP Acute spinal cord section

Aortic coartation Obstructive sleep apnea Preeclampsia/eclampsia

Renal Parenchymal disease Renal cyst (including PCKD) Renal tumor (including Renin-secreting tumors) Obstructive uropathy

Abdomen-pelvic CT (2013/02/21) 1. Diffuse decreased enhancement of both kidney. -> R/O, Medical renal disease. 2. Diffuse enlargement of left adrenal gland without mass -> R/O, Left adrenal hyperplasia. 3. Presumed pneumonia in both lower lobes with bilateral pleural effusion. Addendum) Suspicious luminal narrowing in left proximal renal artery 3.05-2.00/3.05x100 = 34.4%

Miscellaneous endocrine Hypothyroidism Hyperthyroidism Hypercalcemia Acromegaly 결과 참고치 TSH 1.78 0.25~4.0 Free T4 2.29 0.7~2.0 T3 31.01 60~190 Ca 8.2 8.4~10.2

Primary hyperaldosteronism

결과 참고치 Renin 23.12 Supine : 0.15-2.33 Erect : 1.31-3.95 Aldosterone >1800.0 Supine : 8.0-172.0 Erect : 30.0-355.0

Cushing’s syndrome

결과 참고치 ACTH 41.03 10~60 Cortisol (Free 24hr urine) 97.21 75~270

Enzyme deficiency 17α-hydroxylase deficiency 11-hydroxysteroid dehydrogenase deficiency(licorice)

Pheochromocytoma 24hr urine 결과 참고치 Cathecholamine (Epinephrine) 2.05 <40 (Norepinephrine) 13.46 <80 VMA 3.75 2.00~10.00 Plasma 26.35 <400 471.49 <1000 Metanephrine 0.07 0.05~0.34 (2~3x) Normetanephrine 0.75 0.09~0.44 (2~3x)

Impression Malignant HTN Hypertensive retinopathy Hypertensive nephropathy ESRD on HD