발열과 오른쪽 발의 통증을 주소로 내원한 53세 남자 당뇨 환자 Case 2 발열과 오른쪽 발의 통증을 주소로 내원한 53세 남자 당뇨 환자
- 93년 원자력병원에서 type 2 DM 진단받은 후 insulin으로 조절 Chief Complain Rt. foot pain (o/s : 3일 전) Present Illness - 93년 원자력병원에서 type 2 DM 진단받은 후 insulin으로 조절 - 내원 1주일 전 오른쪽 발바닥에 있는 티눈을 잡아뗀 후 피가 났음 - 내원 일주일 전부터 발생한 Rt. foot pain 심해져 외래 방문함 - 본원 성형외과에서 1차 debridement 시행 후 입원
PMHx DM / HTN / Hepatitis / TB (+/+/-/-) DM : 24년 전 진단, Insulin aspart 24U / 12U DM nephropathy, retinopathy HTN : 1년 전 진단, Amlodipine 5mg Qd Furosemide 40mg Qd Op. Hx (+) - 안과 op. d/t vitreal hemorrhage 05년 4월 6일 Personal Hx Smoking (-) Alcohol (+) - 30년간 2~3병/day, 최근 몇 개월간 금주 상태
Review Of System General : fatigue(-) fever(+) chill(+) sweating(-) weight loss (-) poor oral intake (평소량의 1/3로 감소; 3일 동안) Head/Neck : headache(-) visual disturbance(+) soreness(-) hoarseness(-) Respiratory : cough(-) sputum(-) dyspnea(-) Cardiac : chest pain (-) palpitation(-) orthopnea(-)
Gastrointestinal : anorexia(-) nausea(-) vomiting(-) Gastrointestinal : anorexia(-) nausea(-) vomiting(-) abdominal pain(-) diarrhea(+) constipation(-) Urinary : dysuria(-) nocturia (-) frequency(-) hematuria(-) oliguria(+) Musculoskeletal wound of Rt. foot: 3일 전 erythematous change 1일 전 circular hyperpigmentation with bullae swelling(+), burning sensation(+)
Physical examination V/S : 100/60 mmHg - 118 회/min – 20회/min - 38.7°C General appearance - Alert mentality drowsy mentality - Acutely ill-looking appearance Head&Neck - No neck vein engorgement - No cervical lymph node Eye&ENT - Whitish sclera - Pale conjunctiva Chest - Clear breath sound without crackle or wheezing - Rapid & regular heart beats without murmur
Physical examination Abdomen - Soft and flat - Normoactive bowel sound - Tenderness / Rebound tenderness (-/-) Back & Extremity - CVA Td (-/-) - Pretibial pitting edema (-/-) - Rt. Foot : Ankle Dorsi Flexion (+) , 그 외 P/Ex.불가능 Neurology - Rt. Dorsalis pedis artery pulse : not palpable
Initial Laboratory Finding CBC/DC 20310/mm3 - 8.0g/dL - 25.9% - 196K (Seg. : 91.1%) MCV 98.9fL MCHC 30.9g/dL INR : 1.25 % a-PTT : 58.3/33 sec ESR : 39 mm/hr CRP : 29.7 mg/dL Chemistry Prot/Alb 5.5/1.9 g/dL AST/ALT 55/34 IU/L BUN/Cr 77/5.0 mg/dL LD/CK 774/1704 U/L Ca/P 7.2/3.4 mg/dL Na/K/Cl 122/4.3/97 mmol/L Glucose 795 mg/dL Uric acid 10.0 mg/dL ABGA 7.226 - 33.1 - 81.6 - 13.4 - 94.6 sOsm 324.26 HbA1c 6.7 % Myoglobin(s) (8/19) 2456.9 ng/mL U/A Protein > 300mg/dL RBC 2~4 / WBC 5-9 Keton (-) S.G 1.025 FeNa < 1
Foot X-ray (8-18)
Impression # 1. DM Foot Rt. with necrotizing fasciitis # 2. Hyperosmolar syndrome # 3. Acute on CRF # 4. Anemia #5. Known Type 2 DM #6. Known HTN
Plan # 1. DM Foot Rt. with necrotizing fascitis Blood & wound culture X-ray (ankle,tibia-fibula,femur) Antibiotics (ampicillin-sulbactam) & hydration Wound dressing OS consult : surgical debridement 계획 # 2. Hyperosmolar syndrome Normal saline hydration + regular insulin + potassium ABGA, Electrolyte, glucose F/U
# 3. Acute on CRF Hydration & Urine output check BUN/Cr F/U # 4. Anemia reticulocyte, serum Iron, TIBC, vit B12, folic acid, ferritin F/U #5. Known HTN
Clinical Course HD #2 Normal saline hydration : 5L/day Urine output : 480ml I/O = 5840 / 440 Antibiotics : Ampicillin-Sulbactam 3g IV BID (8/18~) Clindamycin 600mg (8/19~) (8/19) Oliguria 상태로 ICU로 T/F (8/20) Furosemide 증량(480mg/day)하면서 Urine output 상승 (Hourly urine 150~250ml/hr 유지됨)
06-8-18 (adm.) 06-8-19 (HD #2)
Ankle X-ray (8-19)
Tibia-Fibula (8-19)
8/19 Femur X-ray
HD #3 (8/20) Emergency OP : I&D, drain tube x2 insertion
OS emergency op (I&D, drain tube x2 insertion) Urine output >200ml/hr Cr : 3.9 mg/dl 8/20 OS emergency op (I&D, drain tube x2 insertion) ABGA : 7.32-28.3-102.4-14.4-97% GMT : 250~300 mg/dL 8/22 Meropenem 1.0g Q 12hrs + Teicoplanin 400mg Q 48hrs Saline irrigation & Potadine wet dressing 8/24 : Citrobacter Koseri (+) 8/25 : E.coli (+) 8/25 Meropenem 1.0g Q 12hrs + Clindamycin 300mg Q 8hrs
Emergency op (below knee amputation:BKA) 시행 8/28 [CRP 11.5 12.2 ] 로 상승 Wound bleeding & swelling 증가, Fever 39°C checked 8/29 Emergency op (below knee amputation:BKA) 시행 Fever (-), CRP감소 Wound culture (-), Wound clear 9/4 9/21까지 Unasyn 1500mg Q12hr 단독 사용 유지 9/24 Fever (-) CRP 0.7 mg/dl Sx 호전되어 퇴원
8/29 Tibia X-ray
9/6 Knee X-ray
Clinical Course #4. Anemia Hb : 6.4 g/dL Hct : 20.6 % MCV : 93.5 fL MCH : 29.1 pg MCHC : 31.2 G/dL TIBC : 255 ug/dL Serum iron : 40 ng/dL Reticulocyte (corrected reti. = 1.09) Folic acid : 2.9 ng/mL Vit. B12 : 464 pg/mL Ferritin : 1031 ng/mL Stool Occult blood (-) Anemia d/t chronic illness (normochromic normocytic)
Furosemide 480mg mix fluid 후 hourly urine 200ml BT(°C) Cr(mg/dl) Furosemide 480mg mix fluid 후 hourly urine 200ml BKA Rt. 2차 I&D 날짜