CASE PRESENTA-TION

PK 2010224029 김지언

PATIENT INFROMATION

성별 / 나이 : 남 /71 세 입원일 : 2013.2.18

키 / 몸무게 : 175cm/56kg

CHIEF COMPLAINT

Vomiting,Hyperglycemia (onset : 5 hours ago)

PRESENT ILLNESS

내원 6 개월전 distal CBD cancer 로 subtotal pan-creaticoduodenectomy with splenectomy 시행하신 분으로

내원 2 개월전 steroid 부작용으로 식도에 염증 생겨 위내시경에서 esophageal candidiasis 생겨 타병원에서 치료후 혈당 조절되어 퇴원한 후부터 점차 잘 먹지 않게 되었다 .

내원일 자가혈당수치 480 으로 혈당 조절 되지 않고 짙은초록빛 액체성 구토 2 번과 함께 입에서 단내가 나는듯 냄새가 나서 응급실 내원하였다 .

PAST MEDICAL HISTORY HTN/DM/Hepatitis/Tb(+/+/-/-)

Hypertension : 내원 1 년전 (on medication) Diabetes mellitus : 내원 6 개월전

Current medication : IR codon 알비스정 암로디핀 에트라빌 보나링에이정 가스모틴정 포탈칼셀 PPI

Drug allergy (-) Allergy Hx (-)  OP Hx

Prostate cancer s/p Radical prostatectomy (2008.5.2)

Distal subtotal pancreatectomy with splecnectomy

Pylorus preserving pancreaticoduodenec-tomy (2012.10.12)

PAST MEDICAL HISTORY Social Hx

음주 흡연

Family Hx 아버지 : 위암으로 사망 어머니 : 당뇨

Trauma Hx 오토바이 사고 (45 년전 )

REVIEW OF SYSTEMS

General     fever(-), chill(-), general weakness(+), cyanosis(-)

HEENT      headache(+), dizziness(+), rhinorrhea(-),

     sore throat(-), hoarseness(-), voice change(-)

  Cardiovascular     chest pain(-), dyspnea of exercise(-), orthopnea(-),

nocturnal dyspnea(-)

Respiratory      cough(-), dyspnea(-), sputum(-), rhinorrhea(-)

    

dizziness(-)

REVIEW OF SYSTEMS

Gastrointestinal      abdominal pain(+), tenderness(+), N/V(+/+), C/D(+/-),

     melena(-), hematochezia(-), hematemesis(-), steator-rhea (-)

  Urinary      voiding difficulty(-), dysuria(-), frequency(-), hema-

turia(-)

nocturia(-), urgency(-), incontinence(-), hesistancy(-)

residual urine sense(-)

Back & Extremity back pain(+), muscle weakness(-), arthralgia(-),

tremor(-)

abdominal pain(-), tenderness(-), N/V(-/-)

PHYSICAL EXAMINATION Vital sign >

110/70mmHg-88 회 / 분 -23 회 / 분 -36.2 ℃

General>

Height : 175cm Weight : 56kg (BMI : 18.3)

chronic ill appearance

HEENT>

    anicteric sclera, not pale conjunctiva, PI(-), PTH(-/-)

Chest>

   Bilateral symmetric expansion

   clear breathing sound without crackle & wheezing

   regular heart beat without murmur     

PHYSICAL EXAMINATION

Abdomen>    abdomen soft, normoactive bowel sound, tender-

ness(-)

Back&Ext.>     pretibial pitting edema (-/-), CVAT (-/-),

dorsal pedalis a. pulse intact

LABATORY FINDINGS

CBC

WBC 11800

neutrophil 76.1%

lymphocyte 17.3%

monocyte 5.1%

Eosinophil/Basophil 0.4/0.4

Hb 11.0

Hct 36.4

Platelet 342000

LABATORY FINDINGS

Chemistry

Glucose 533

BUN/Cr 12/1.1

AST/ALT 34/9

Bilirubin 0.9

LDH/ CK 273/41

Na/K/Cl 132/3.8

Cl/CO2 36.4

LABATORY FINDINGS

Blood gas analysis

Glucose 533

BUN/Cr 12/1.1

AST/ALT 34/9

Bilirubin 0.9

LDH/ CK 273/41

Na/K/Cl 132/3.8

Cl/CO2 36.4

LABATORY FINDINGS

Blood gas

pH 7.432 7.38 - 7.44 PCO2 14.3 mmHg ▼ 35 - 40 PO2 151.2 mmHg ▲ 95 - 100 HCO3 9.3 mmol/L ▼ 23 - 29 TCO2 9.8 mmol/L ▼ 27 - 28 BE -12.5 mmol/L ▼ -2 - 3 SaO2 99.1 %Lactate 6.69 mmol/L ▲ 0.5 - 2

LABATORY FINDINGS

Na 51K 22.6Cl 8Creatinine 19.3Osmolality 440.00 mOsm/Kg

Osmolality 288.7 mOsm/Kg

LABATORY FINDINGS

ESR/C-ESR 20 mm/hr ▲ 0 - 9

Creat clea 69 ml/min ▼ 97 - 137

Urine 24hrProtein(T) 124.2 mg/day ▲ 1 - 114Creatinine 0.5 g/day ▼ 0.6 - 2.5

Bone ALP 12.70 U/L6 - 30☞ Clinical Notice

F: Premenopausal : 3.00 - 19.00

Postmenopausal : 6.00 - 26.00

25(OH) Vit 8.73 ng/ml4.8 - 52.8

LABATORY FINDINGS

Protein(T) 6.3 g/dl ▼ 6.5 - 8.2Albumin 3.2 g/dl ▼ 3.5 - 5T-Chol 144 mg/dl 141 - 239

☞ Clinical Notice

Borderline : 200 - 239 mg/dl Ca 8.6 mg/dl ▼ 8.7 - 10.2ALP 79 U/L D 47 - 120Bil(D) 0.24 mg/dl D 0 - 0.3γ-GTP 17 U/L D 8 - 63Inor-Phos 1.1 mg/dl ▼ D 2.4 - 4.7TG 102 mg/dl 0 - 200HDL-C 39 mg/dl 31 - 68LDL-choles 71 mg/dl 0 - 130Apo A1 109 mg/dl 90 - 120Apo B 99 mg/dl 60 - 155

LABATORY FINDINGS

Protein(T) 124.2 mg/day ▲

1 - 114Creatinine 0.5 g/day ▼

0.6 - 2.5

Hb A1C %4.8 - 6

HbA1c-NGSP 7.1 % ▲4.8 - 6

HbA1c-IFCC 54 mmol/mol▲ 20 - 42

HbA1c-eAG 157 mg/dl ▲0 - 125

LABATORY FINDINGS

U/A 10종 SG >=1.030 1.005 - 1.03 PH 5.0 5 - 8 Leucocyte - - Nitrate - - Protein - - Glucose ++++ - Ketone +++ P - Urobilinog +- +- Bilirubin - - Blood - -Urine Micr RBC <1 HPF 0 - 5 WBC <1 HPF 0 - 5 Epithelial . HPF Bacteria moderate 12 x10^3/mL

Hyaline ca <1 /LPF Other LPF

Chest X-ray

PROBLEM LIST

#1. Hyperglycemia

#2. Nausea, Vomit, Abdominal pain

#3. Poor oral intake

#4. Back pain

#5. Known Hypertension

#6. Known distal CBD cancer s/p

#7. Known prostate cancer s/p

ASSESSMENT

#1. Diabetic ketoacidosis

#2. Known Diabetes mellitus

#3. Known Hypertension

#4. Known distal CBD cancer s/p

PLAN

#1. Diabetic ketoacidosis

Diagnostic Plan>

Urine analysis

Therapeutic Plan>

Check Vital sign

Keep bed rest

Antibiotics (carbapenem 계열 )

PLAN

#2. Rule out Neurogenic bladder

Diagnostic Plan>

Follow up Physical examination

Urodynamic study

Therapeutic Plan>

Kegel exercises

Anticholinergics (vesicare)

PROGRESSION NOTEHD#3

O>

Vital sign : 110/70-72-20-36.6

Frequency(+)

A>

#1. Rule out Acute cystitis

#2. Rule out Neurogenic bladder

P>

Keep bed rest

Antibiotics

Anticholinergics

REVIEW OF DISEASE DIABETIC KETOACIDOSIS

Inflammatory response of the urothe-lium to bacterial invasion that is usu-ally associated with bacteriuria and pyuria.

Leading cause of morbidity and health care expenditures in persons of all ages.

An estimated 50 % of women report having had a UTI at some point in their lives.

URINARY TRACT INFECTIONS

DIAGNOSTIC FLOWCHART

DIAGNOSTIC FLOWCHART

DIAGNOSTIC FLOWCHART

Most cases of uncom-plicated cystitis occur in women.

more than 50% of all women have at least one such infection in their lifetime

ACUTE UNCOMPLICATED CYSTITIS

The microbiology is lim-ited to a few pathogens.

70%- 85% are caused by Escherichia coli

5-20%are caused by co-agulase-negative Staphy-lococcus saprophyticus

5-12% are caused by other Enterobacteriaceae such as Klebsiella and Proteus.

ACUTE UNCOMPLICATED CYSTITIS

Clinical Features: dysuria, fre-quency, urgency, suprapubic pain, hematuria. Fever >38C, flank

pain, costoverte-bral angle tender-ness, and nausea or vomiting sug-gest upper tract infection.

ACUTE UNCOMPLICATED CYSTITIS

Diagnosis: direct history and PE

PE: Temperature, abdominal exam, assessment of CVA tenderness, pelvic exam. H/o STD’s, new sexual partner, partner

with urethral symptoms, gradual onset.

ACUTE UNCOMPLICATED CYSTITIS

UA: Evaluation of midstream urine for pyuria. White blood cell casts in the urine are Dx of

upper tract infection.

Urine Culture: Not necessary (Rou-tine) symptomatic patients the presence of

102 cfu/mL or more of urine usually in-dicates infection

Warranted in: Suspected complicated infec-tion, persistent symptoms following tx, symptoms recur < 1 mo after tx.

ACUTE UNCOMPLICATED CYSTITIS

MANAGEMENT

TREATMENT

TMP and TMP-SMX are effective and inexpensive agents for empiri-cal therapy, resulting in bacteriologic cure (i.e., eradication of the pathogen from the urine) within 7 days after the start of treatment in approximately 94% of women (Warren et al, 1999).

They are recommended in areas where the prevalence of resistance to these drugs among E. coli strains causing cystitis is less than 20%

REFERENCE

Harrison's Principles of Internal Medicine, 18th Edition, Chapter 288. Urinary Tract Infections, Pyelonephritis, and Prostatitis

Campbell-Walsh Urology, 10th Edition, Chapter 10. Infections of the Urinary Tract

THANK YOU FOR YOUR ATTEN-TION