im4 case report 최 0 옥 m/52

IM4 Case Report최 0 옥 M/52본과 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 2011. 03. 20 BSL control 위해 입원 함

(Multiple Diary Injection 고려 )

Past Medical History 당뇨병 (+) 고혈압 (+)간염 (-) 결핵 (-)알레르기 (-) 항생제 알레르기 (-)

2010. 07. 23. Micro-Vascular Decompres-sion for

Hemifacial Spasm (NS)

Family History 가족 중 당뇨 , 고혈압 환자 없음

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

Review of System – (1) GW/EF (-/-) weight loss (-)

poor oral intake(-) blurred vision(-)

night sweating(-)

Fever/Chill (-/-) Headache/Dizzi-ness(-/-)

Review of System – (2) R/C/S (-/-/-) sore throat (-) oral pain(-) hemoptysis (-) dyspnea (-) sweat-

ing(-) chest pain (-) palpitation (-)

Review of System – (3) abdominal pain (-) discomfort (-) A/N/V/D/C

(-/-/-/-/-) melena/hematochezia/hematemesis (-/-/-)

myalgia /arthralgia (-/-) easy bruisibility (-)

urinary Sx (+) : frequency

tingling sensation (-)

Physical Examination – (1) 81.8kg 171.3cm BMI 27.8 Vital sign 168/105 – 70 – 20 – 36.0

General Appearance not so ill-looking Mental status alert Orientation well oriented

Physical Examination – (2) Head & Neck

Anemic conjunctivae No

Icteric sclerae No

Dehydrated tongue No

Tonsilar Hypertrophy No

Pharyngeal Injection No

Physical Examination – (3) Chest

Symmetric Chest Expansion

Regular heart beat, no murmur

Clear breathing sound at both lung

Physical Examination – (4) Abdomen

Soft & Flat

Bowel sound Normoactive

Tenderness No

Rebound tenderness No

Physical Examination – (5) Back & Extremity

CVAT No

Pitting Edema No

Skin lesion No

Physical Examination – (6) Peripheral Neurological Test

Vibration scale 35/20

Temp sense +/+

Monofilament sense 10/10

Dorsalis pedis +/+

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

Assessment – 1st

I. #1, #3, #5, #6 R/O DM Neuropathy R/O DM Nephropathy R/O DM Retinopathy R/O Peripheral artery Disease

Diagnostic plan CBC Chemistry Electrolyte Urinalysis Glucose Antibody Screening

Chest X-ray (routine)

ANF

Diabetic vascular test Fundoscopy Carotid IMT CPT ABI

Lab – CBC WBC 5.88 x10³/μL

RBC 4.75 x10³/μL

Hb 15.1 g/dL Hct 44.4%

PLT 154,000/μL

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

Lab – Chemistry (2) AST 31 U/l

ALT 37 U/l

ALP ▼ 48 U/l

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

Lab – Chemistry (4) Glucose, fasting▲ 239 mg/dl

HbA1c 9.9 %

Insulin ▲ 80.5 uIU/ml

C-peptide 5.65 ng/ml

Lab – Chemistry (5) Triglyceride 174 mg/dl

HDL-C 49 mg/dl

LDL-C 108 mg/dl

Free fatty acid ▲ 694 uEq/

Lab – Electrolyte Na 143 mmol/ℓ

K 3.7 mmol/ℓ

Cl 102 mmol/ℓ

Lab – Urinalysis Creatinine, urine 27.54 mg/dl

Microalbumin ▲ 11.45 mg/dl

ALB/Cr ratio, urine ▲ 415.76 ug/mgCr

Lab – Glucose Poorly controlled

Lab – Antibody Screening Negative

Imaging – CXR Normal Heart Size No tracheal deviation No active lesion

ANF

ANF 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

Early autonomic dysfunction

Imaging – Fundoscopy No DM change

No microaneurysm No hard exudate No soft exudate No retinal hemorrhage No neovascularization

Imaging – Carotid IMT Both common and internal carotid arteries

No Wall thickening, No PlaqueDistalCCA Bulb

ProximalICA

Right 0.54mm 0.45mm 0.37mm

Left 0.56mm 0.47mm 0.42mm

Imaging – CPT Lt. peroneal nerve : normal

normal

Rt. Peroneal nerve Grade 7.00 의 mild hypoes-

thesia

Segmental limb pressure, waveform, ABI Both Femorotibial arteries 에서 triphasic wave-

form

Segmental limb pressure, waveform, ABI

Imaging – EKG Normal Sinus Rhythm

LVH 없음Left Deviation ; Lead I (+) &

aVF (-)

Imaging – Abdomen US Liver 의 크기와 모양은 정상이나 parenchymal echo가 전체적으로 증가되어 있음 . 내부에 뚜렷하게 그려지는 focal mass 없음 .

Imaging – Abdomen US Left kidney 에 약 1.8 cm 의 cystic echo 가 관찰됨 .

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.

Assessment – 2nd

I. #1, #3, #5, #6 R/O DM Neuropathy (mild 하게 존재 ) R/O DM Nephropathy (Cr 등 정상 ) R/O DM Retinopathy (Fundoscopy 정상 ) R/O Peripheral artery Disease

II. #6, #7 R/O Fatty Liver

Therapeutic Plan Blood Glucose Level Control

Continuous HTN Control

금연 , 음주 교육 ( 지방간 관련 )

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

Treatment of Fatty liver 원인 제거 및 생활습관 개선이 중요

체중감량 , 지방섭취 제한 , 운동