C A S E 내분비대사내과 R3 김석연. 11160382 문 0 자 F/65 adm.)2006.04.27 C.C ) for DM manage P.I ) DM 으로 18 년전 부터 외래 F/U 하며 DM 조절 중 인 환자로 poor oral intake 있어 약 한달.

Presentation on theme: "C A S E 내분비대사내과 R3 김석연. 11160382 문 0 자 F/65 adm.)2006.04.27 C.C ) for DM manage P.I ) DM 으로 18 년전 부터 외래 F/U 하며 DM 조절 중 인 환자로 poor oral intake 있어 약 한달."— Presentation transcript:

1 C A S E 내분비대사내과 R3 김석연

2 11160382 문 0 자 F/65 adm.)2006.04.27 C.C ) for DM manage P.I ) DM 으로 18 년전 부터 외래 F/U 하며 DM 조절 중 인 환자로 poor oral intake 있어 약 한달 전 부터 insulin 자가주사 게을리 하며 지냈고 이후 식사량 증가하였으나 동네사람의 insulin 이 몸에 나쁘다는 말 듣고 insulin 맞지 않았다고 함. 일주일전 외래 내원 당시 HbA1c 12.8%, PP2hr 584 로 확인되어 당조절 위해 입원함.

3 P.H) HTN (+) DM(+) 아침 식전 MXP37 30 units s.c TB (-) Hepatitis (-) CHF d/t IHD (+) `03.8. EF = 36% TB (-) Hepatitis (-) CHF d/t IHD (+) `03.8. EF = 36% opHx.(+) `95. 9. colon ca. subtotal colectomy & opHx.(+) `95. 9. colon ca. subtotal colectomy & ileosigmoidostomy ileosigmoidostomy `05. 5. both eyes cataract op. ( local OPH) `05. 5. both eyes cataract op. ( local OPH) `05. 11. Rt. 4, 5th foot toes open amputation `05. 11. Rt. 4, 5th foot toes open amputation PHx) smoking (-) alcohol (-) Occupation) 주부 DM Alcoholic LC

4 Review of systems General fatigue(-)fever(-) chill(-) Wt.loss(-) Skin rash(-) pigmentation(-) H&N headache(-)neck stiffness(-) sore throat(-) Respiratory cough(-)sputum(-) dyspnea(-) Cardiac angina(-)orthopnea(-) palpitation(-) G-I anorexia(-)vomiting(-) nausea(-) pain(-) constipation(+) Renal dysuria(-)hematuria(-) incontinence(-)nocturia(-) frequency(-) M&S weakness(-) sensory change (-)

5 Physical examination V/S 130/80mmHg – 68 회 /min – 20 회 /min - 36.7°C G/A BW :54 kg HT: 156 cm BMI 22.18 kg/m² Alert consciousness Chronic ill appearance Head & Neck Normocephaly No cervical LN enlargement No neck vein engorgement No thyroid enlargement Eyes & ENT Isocoric pupil PLR(++/++) pale conjunctiva(-) Yellowish sclera(-)

6 Physical examination Chest Clear breathing sound without rale or wheezing Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness(-) Rebound tenderness(-) Shifting dullness(-) Back & Ext. No CVA tenderness Both pretibial pitting edema(-/-) Neurology motor sensory V V 100 100

7 Lab. finding I CBC/DC 5,080/mm 3 – 9.4g/dL – 27.4% - 303K/mm 3 (seg. 55.3% ) INR 1.05 MCV 90.8 fL(80~96 fL) MCH 31.4 pg (27~33 pg) Chemistry TB/DB 0.50 / 0.12 mg/dL (0.0-1.1mg/dL) Prot./Alb.5.8 / 32.9 g/dL (5.8~8.0/3.1-5.2 g/dL) AST/ALT17 / 12 U/L (<40/<40 U/L) Glucose 321mg/dL ALP 71 U/L (39-117 U/L) LD/CK 495 / 132 U/L (218~472/38~160U/L) BUN/Cr21 / 1.8 mg/dL (8-23/0.6-1.2 mg/dL) Na/K/Cl 136 / 4.9/ 104 mmol/L (135-145/3.5-5.0/95-110 mmol/L) Ca/P 8.9 / 3.6 mg/dL (8.4-10.2/2.5-5.5mg/dL) Mg/Uric acid2.2/ 5.4 mg/dL (1.5-2.5/3.0~8.3mg/dL)

8 Lab. finding II TG/T-Cholesterol 529/ 210mg/dL ( <150 /<200 mg/dL) HDL/LDL 25/107 mg/dl ( >40 /<130 mg/dL) Anemia study reticulocyte 2.27% (0.5~2%) absolute reticulocyte count 1.38 serum iron 99 ug/dL (50~150 ug/dL) TIBC 226 ug/dL(200~400) Ferritin 173ng/ml ( 15~332) Vt B12 1915 pg/nl (160~970) Folate 10.6ng/ml (>1.5ng/ml) Stool OB(-) U/A Prot. 100mg/dL glucose >2.0g/dL pH 5.5 RBC 0~1/HPF WBC 0~1/HPF nitrite(-)

9 Chest PA (06-04-27)

10 ECG(06-04-27)

11 Impression Uncontrolled DM Diadetic nephropathy Dyslipidemia Anemia d/t chronic illness HTN CHF d/t IHD s/p colon ca. s/p amputation Rt. 4,5th toes

12 Therapeutic plan DM manage - insulin 용량조절 (multiple inj.) - complication study - 당뇨교육, 영양상담

13 IMT (`06.04.28)

14 `06.04.29(HD3) PM 02:00 epigastric discomfort – 환자와 보호자 소화불량으로 생각하고 약국에서 소화제 사서 먹음. PM 05:00 epigastric discomfort & sweating sign 보이며 dyspnea 심해진 후 apnea 발생하여 intubation 시행함. SBP100mmHg 유지 cardiac compression 시행 안함. ECG: new onset LBBB CK 138 U/L (38~160U/L) Heart enzyme : CK 138 U/L (38~160U/L) CK-MB 6.4ng/mL (0.6~6.3 ng/mL) CK-MB 6.4ng/mL (0.6~6.3 ng/mL) TnI 0.06 ng/mL (<0.04 ng/mL) TnI 0.06 ng/mL (<0.04 ng/mL) myoglobin 232 ng/mL (14~65 ng/mL) myoglobin 232 ng/mL (14~65 ng/mL) NSTEMI MICU care & mechanical ventilation LMWH & NTG

15 ECG(06-04-27)

16 Chest PA (06-04-29)

17 06/04/2917:0006/04/2919:0006/04/2923:0006/04/3006/05/01 CK (38~160U/L) (38~160U/L) 138205515330280 CK-MB (0.6~6.3ng/mL) 6.517.575.571.823.8 TnI (<0.04ng/mL) 0.060.233.544.82 Clinical course

18 `06.05.01(HD5) AM 07:30 SBP 60mmHg 이하로 떨어지며 VT 발생함. defibrillator 100J 1 회, 200J 2 회 시행. cardiac arrest 발생. CPR 25 분 가량 시행 (cardiac compression) AM 08:00 SBP 회복되며 saturation 유지됨. Inotrophics (dopamine 유지 ) ECG 에서 VPCs 만 관찰되는 소견 보임. CMV mode & full sedation 시행

19 환자 mental alert 해짐. FIO2 0.3- 99% 환자 mental alert 해짐. FIO2 0.3- 99% T-piece weaning 시행함. 약 1 시간 시행 T-piece weaning 시행함. 약 1 시간 시행 Chest wall pain 호소하며 paradoxical wall motion 관찰됨. Chest wall pain 호소하며 paradoxical wall motion 관찰됨. Saturation 유지 안됨. Saturation 유지 안됨. `06.05.03(HD7) Flail chest

20 동영상

21 ` Heart spect `03.08.21 Heart spect

22 `03. 08.18 Cardiac echo Depressed LV function ( EF = 36% ) akinesia of ant. lateral. inf. wall of apex - base

23 `05-11-11 cardiac echo EF = 41%

24 비침습적 동맥경화협착검사 (`05.7.16)

25 전류인지역치검사 (`05.7.16)

26

27 신경전도검사 (`05.7.18)

28 자율신경병증검사 (`05.7.16)

29 `05. 09.07

30 Final diagnosis Poor controlled DM Poor controlled DM with acute myocardiac infarction with acute myocardiac infarction with neuropathy, nephropathy, retinopathy with neuropathy, nephropathy, retinopathy Flail chest d/t CPR Flail chest d/t CPR

31 Flail chest

32 Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration Significant force required Significant force required Usually diagnosed clinically Usually diagnosed clinically Can be missed early, d/t muscle splinting Can be missed early, d/t muscle splinting

33 Sx of Flail Chest Shortness of Breath Shortness of Breath Paradoxical Movement Paradoxical Movement Bruising/Swelling Bruising/Swelling Crepitus( Grinding of bone ends on palpation) Crepitus( Grinding of bone ends on palpation)

34 Paradoxical chest wall movement Paradoxical chest wall movement Expiration expansion of chest wall Inspiration collapse of chest wall

35 Flail chest

36 Flail Chest - detail

37 Complication Pneumonia, ARDS, Pneumothorax, Hemothorax Pneumonia, ARDS, Pneumothorax, Hemothorax Atelectasis Atelectasis Pulmonary function Pulmonary function Ventilation ineffective – increased energy Ventilation ineffective – increased energy Lung contusion – hypoxia Lung contusion – hypoxia Atelectasis, muscle fatigue Atelectasis, muscle fatigue

38 Treatment Pain control Skeletal splinting with ext. weight on the flail segment Internal splinting with positive pressure ventilation Surgical fixation of the flail region Thoracic and shoulder chest physiotheraphy

39 CPR Combines rescue breathing and chest compressions Combines rescue breathing and chest compressions Revives heart and lung functioning Revives heart and lung functioning Use when there is no breathing and no pulse Use when there is no breathing and no pulse Provides O 2 to the brain Provides O 2 to the brain

40 Hand Placement for CPR 가슴이 4~5cm 정도 함몰되도록 압박 압박하는 속도는 1 분에 100 회 정도 압박과 이완의 비율은 50:50 정도

41 How CPR Works Effective CPR provides 1/4 to 1/3 normal blood flow Effective CPR provides 1/4 to 1/3 normal blood flow Rescue breaths contain 16% oxygen (21%) Rescue breaths contain 16% oxygen (21%)

42 Injuries Related to CPR Rib fractures Rib fractures Laceration related to the tip of the sternum Laceration related to the tip of the sternum Liver, lung, spleen Liver, lung, spleen

43 When to Stop CPR Cardiac arrest of longer than 30 minutes Cardiac arrest of longer than 30 minutes controversial controversial