Case Conference 내분비 대사 내과 R1 송 란

11748684 원민희 (F/27) 입원일: 05.12.06 주소: 질 출혈을 동반한 무월경 시작일> 2004년10월14일 현병력 평소 건강히 지내던 27세 여자 환자 (미혼, 미산부) 04년10월14일 부터 질 출혈을 동반한 8주의 무월경 발생 04년11월29일 동네 산부인과 병원(순풍산부인과) 내원. 초음파 검사에서 포상기태 (hydatidiform mole) 의심되어 자세한 검사 및 치료 위해 본원 산부인과 입원. 과거력 고혈압(-) 당뇨(-) 결핵(-) 간염(-) 갑상선질환 (-) 수술력(-) 약 복용력(-) 산과력 : 임신 중절(+) - 2회 ( 99년, 01년) 가족력 : 특이 사항 없음 개인력 : 음주(-) 흡연(-)

Review of System General : fatigue(-) fever(-) chills(-) sweat(-) weight loss(-) Skin : rash(-) pigmentation(-) Itching(-) Head & Neck : headache(-) trauma(-) stiiffness(-) Eye & ENT : sore throat(-) dry mouth(-) visual disturbance(-) hearing loss(-) Respiratory : cough(-) sputum(-) dyspnea(-) Cardiac : palpitation(-) chest discomfort(-) orthopnea(-) Gastrointestinal : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) Urinary : dysuria(-) nocturia(-) frequency(-) Gynecology : menorrgagia(-) amenorrhea(+) vaginal spotting(+) Endocrine : polydipsia(-) heat intolerance(-) Musculoskeletal : myalgia(-) weakness(-) numbness(-) Neurology : dizziness(-) tremor(-)

Physical Examination V/S : 140/90 mmHg-120회/min-20회/min-36.4°C height: 159 cm body weight: 50 kg BMI: 19.7 kg/m2 General apperance alert conciousness Acutely ill appearance Skin no rash or pigmentation, skin turgor : normal Head & Neck normocephaly no neck vein engoregement no cervical LN enlargement no thyroid gland enlargement , no tenderness no definite thyroid nodule or mass Eye & ENT isocoric pupil with PLR(+/+) pinkish conjunctiva clear sclera Pharyngeal injection(-) paratonsilar hypertrophy(+/+)

Thorax symmetric chest expansion clear breathing sound without rale rapid & 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(-/-) Pelvic Examination uterus: anterior version, 2 finger below umbilicus level adnexa : both not palpable cervix : not erosion vaginal dyscharge(+) :leukorrhea, scanty

Impression Hydatidiform mole (H-mole)

Plan β-HCG Transvaginal sonography Abdominal CT

Chest X-ray ( 05.12.06 )

EKG ( 05.12.06 )

Laboratory Finding ( 05.12.06 ) CBC/DC 8930/mm3 -10.2 g/dL-29.4 %-271000 INR :1.06 a-PTT : 30 C 32 Chemistry TB/DB 0.3/0.1 mg/dL AST/ALT 34/32 IU/L ALP 30 IU/L Prot/Alb 6.0/3.6 g/dL Glucose 114 mg/dL Ca/P/Mg 9.2/3.4/2.1 mg/dL BUN/Cr 11/0.5 mg/dL Na/K/Cl 139/4.5/105 mmol/L UA RBC 0-1/HPF WBC 0-1/HPF O.B.:2+ Ketone(-) Glucose(-) Protein(-) SG: 1.025 pH: 5.5 β-HCG :1501720 mIU/mL (NL< 5 mIU/mL)

Transvaginal Sonography (04.12.06) Ut.size : 10.7x11.2x 8.4 cm

Abdominal CT – I (04.12.07)

Abdominal CT - II (04.12.07)

Diagnosis Hydatidiform mole (H-mole)

Therapeutic Plan Dilatation and curratage (D&C) Chemotherapy (Methotrexate)

Thyroid Function Test (04.12.08) T3 (NL: 80~200 ng/dl) 511 Free T4 (NL: 0.77~1.94 ng/dl) 4.50 TSH (NL:0.3~4.0 u/ml) 0.13

Impression II β-HCG induced Hyperthyroidism r/o Graves´ disease

Diagnostic plan Thyroid uptake & scan (iodine) TG Ab.,TMS ,TBII D&C 후 TFT F/U

TG Ab. (NL: <100 IU/ml) <50 TMS (NL: <8 ug/ml) 0.01 TBII (NL: <10 %) 2.2 <04.12.12>

Thyroid uptake & scan (I-131):04.12.16. Radioactive iodine uptakes 2hr = 6.6 % 24hr = 14.6 %

Clinical Cource D & C 2회 (2004.12.08, 2004.12.16) Pathology Chemotherapy (methotrexate 50 mg qd.):04.12.16~04.12.23 <04.12.08> <04.12.16>

Methotrexate (12/16~12/23) β-HCG TFT 날짜 04/12/07 (pre op.) 04/12/9 (post op.1D) 04/12/15 (post op.7D) 04/12/23 (post op.15D) 04/12/31 (post op.23D) 05/1/11 (post op.34D) 05/1/25 (post op.48D) 05/2/01 (post op.55D) β-HCG (NL<5 mlU/mL) 1501720 246600 10247 1860 442 109.1 35 25 04/12/8 D&C 04/12/16 D&C 04/12/06 (pre op.) 04/12/17 (post op. 9D) 04/12/30 (post op. 21D) T3 (NL: 80~200 ng/dl) 511 137 185 Free T4 (NL: 0.77~1.94 ng/dl) 4.50 1.58 1.19 TSH (NL: 0.3~4.0 u/ml) 0.13 0.09 0.72

Final Diagnosis Hydatidiform mole β-HCG induced Hyperthyroidism