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IM4 Case Report 최 0 옥 M/52

IM4 Case Report 최 0 옥 M/52. 본과 3 학년 2007313075 손의영. Chief Complain. For Blood Sugar Level Control No prominent Symptoms. Present Illness. 2003. 03 건강 검진에서 DM 발견 . 이후 경구 혈당 강하제로 BSL control 2007. 08 Insulin Start 이 후 계속적으로 insulin level 과 경구약을 증량 하였으나 BSL control 이 잘 이루어 지지 않음

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IM4 Case Report 최 0 옥 M/52

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  1. IM4 Case Report최0옥 M/52 본과 3학년 2007313075 손의영

  2. Chief Complain • For Blood Sugar Level Control • No prominent Symptoms

  3. Present Illness • 2003. 03건강 검진에서 DM 발견. 이후 경구 혈당 강하제로 BSL control • 2007. 08Insulin Start • 이 후 계속적으로 insulin level과 경구약을 증량 하였으나 BSL control이 잘 이루어 지지 않음 • 2011. 03. 20 BSL control 위해 입원 함 (Multiple Diary Injection 고려)

  4. Past Medical History • 당뇨병 (+) 고혈압 (+)간염 (-) 결핵 (-)알레르기 (-) 항생제 알레르기 (-) • 2010. 07. 23. Micro-Vascular Decompression for Hemifacial Spasm (NS)

  5. Family History • 가족 중 당뇨, 고혈압 환자 없음

  6. Social History • Smoking 하루 2갑, 30년 • Alcohol 소주 2병, 일주일에 4~5번

  7. Review of System – (1) • GW/EF (-/-) weight loss (-) • poor oral intake(-) blurred vision(-) • night sweating(-) • Fever/Chill (-/-) Headache/Dizziness(-/-)

  8. Review of System – (2) • R/C/S (-/-/-) sore throat (-) oral pain(-) • hemoptysis (-) dyspnea (-) sweating(-) • chest pain (-) palpitation (-)

  9. Review of System – (3) • abdominal pain (-) discomfort (-) A/N/V/D/C (-/-/-/-/-) • melena/hematochezia/hematemesis (-/-/-) • myalgia /arthralgia (-/-) easy bruisibility (-) • urinary Sx (+) : frequency • tingling sensation (-)

  10. Physical Examination – (1) • 81.8kg171.3cmBMI 27.8 • Vital sign 168/105 – 70 – 20 – 36.0 • General • Appearance not so ill-looking • Mental status alert • Orientation well oriented

  11. Physical Examination – (2) • Head & Neck • Anemic conjunctivae No • Ictericsclerae No • Dehydrated tongue No • Tonsilar Hypertrophy No • Pharyngeal Injection No

  12. Physical Examination – (3) • Chest • SymmetricChest Expansion • Regular heart beat, no murmur • Clear breathing sound at both lung

  13. Physical Examination – (4) • Abdomen • Soft & Flat • Bowel sound Normoactive • Tenderness No • Rebound tenderness No

  14. Physical Examination – (5) • Back & Extremity • CVAT No • Pitting Edema No • Skin lesion No

  15. Physical Examination – (6) • Peripheral Neurological Test • Vibration scale 35/20 • Temp sense +/+ • Monofilament sense 10/10 • Dorsalispedis+/+

  16. Problem List • #1. DM, poorly controlled • #2. Mild overweight • #3. Hypertension • #4. HFS s/p MVD • #5. Heavy Smoker • #6. Alcoholics

  17. Assessment – 1st • I. #1, #3, #5, #6 • R/O DM Neuropathy • R/O DM Nephropathy • R/O DM Retinopathy • R/O Peripheral artery Disease

  18. Diagnostic plan • CBC • Chemistry • Electrolyte • Urinalysis • Glucose • Antibody Screening • Chest X-ray (routine) • ANF • Diabetic vascular test • Fundoscopy • Carotid IMT • CPT • ABI

  19. Lab – CBC • WBC 5.88 x10³/μL • RBC 4.75 x10³/μL • Hb15.1 g/dL • Hct44.4% • PLT 154,000/μL

  20. Lab – Chemistry (1) • Protein 6.2 g/㎗ • Albumin 4.3 g/㎗ • Globulin 2 g/㎗ • PT 13 sec 103% 0.98 INR • APTT 29.7 sec

  21. Lab – Chemistry (2) • AST 31U/l • ALT 37U/l • ALP ▼48U/l

  22. Lab – Chemistry (3) • BUN 14.8 mg/dl • Cr ▼0.61 mg/dl • BUN & Cr ▲24.3 • Estimated GFR 133.8 mL/min • Uric acid 4.9 mg/dl • Ca 9.1 mg/dl • P 3.6 mg/dl

  23. Lab – Chemistry (4) • Glucose, fasting▲239 mg/dl • HbA1c 9.9 % • Insulin ▲ 80.5 uIU/ml • C-peptide 5.65 ng/ml

  24. Lab – Chemistry (5) • Triglyceride 174 mg/dl • HDL-C 49 mg/dl • LDL-C 108 mg/dl • Free fatty acid ▲694 uEq/

  25. Lab – Electrolyte • Na 143 mmol/ℓ • K 3.7 mmol/ℓ • Cl 102 mmol/ℓ

  26. Lab – Urinalysis • Creatinine, urine 27.54 mg/dl • Microalbumin ▲11.45 mg/dl • ALB/Cr ratio, urine ▲415.76 ug/mgCr

  27. Lab – Glucose • Poorly controlled

  28. Lab – Antibody Screening • Negative

  29. Imaging – CXR • Normal Heart Size • No tracheal deviation • No active lesion

  30. ANF

  31. ANF Early autonomic dysfunction • Early Autonomic dysfx. • I. 1/2 OR II. 1/3 • Definite … • I. 1/2 AND II. 2+/3 • Severe … • I. 1+/2 AND II. 2+/3 • WNL • All Normal

  32. Imaging – Fundoscopy • No DM change • No microaneurysm • No hard exudate • No soft exudate • No retinal hemorrhage • No neovascularization

  33. Imaging – Carotid IMT • Both common and internal carotid arteries • No Wall thickening, No Plaque

  34. Imaging – CPT • Lt. peroneal nerve : normal • normal • Rt. Peroneal nerve • Grade 7.00의 mild hypoesthesia

  35. Segmental limb pressure, waveform, ABI • Both Femorotibial arteries에서 triphasic waveform

  36. Segmental limb pressure, waveform, ABI

  37. Imaging – EKG LVH 없음 Left Deviation ; Lead I (+) & aVF(-) • Normal Sinus Rhythm

  38. Imaging – Abdomen US • Liver의 크기와 모양은 정상이나 parenchymal echo가 전체적으로 증가되어 있음. • 내부에 뚜렷하게 그려지는 focal mass 없음.

  39. Imaging – Abdomen US • Left kidney에 약 1.8 cm의 cystic echo가 관찰됨.

  40. Problem List • #1. DM, poorly controlled • #2. Mild overweight • #3. Hypertension • #4. HFS s/p MVD • #5. Heavy Smoker • #6. Alcoholics • #7. Fatty liver • #8. A 1.8 cm cystic echo in the left kidney.

  41. Assessment – 2nd • I. #1, #3, #5, #6 • R/O DM Neuropathy (mild하게 존재) • R/O DM Nephropathy (Cr 등 정상) • R/O DM Retinopathy (Fundoscopy정상) • R/O Peripheral artery Disease • II. #6, #7 • R/O Fatty Liver

  42. Therapeutic Plan • Blood Glucose Level Control • Continuous HTN Control • 금연, 음주 교육(지방간 관련)

  43. Treatment of DM – Goal • Blood Pressure • SBP < 130, DBP < 80 mmHg • ACEi, ARB: drug of choice • Lipid management • LDL < 100, HDL > 50, TG < 150 mg/dL • Overt CVD: LDL < 70 • Statin • Antiplatelet agents

  44. Treatment of Fatty liver • 원인 제거 및 생활습관 개선이 중요 • 체중감량, 지방섭취 제한, 운동

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