Case Conference 내분비 대사 내과 R1 우용식

양수희 ( F/59 ) adm : Chief complain sweatingoneset – 3 yrs ago; gradually intermittent Present illness F/58 약 3 년 전부터 facial flushing, sweating 증세 있어서 본원 내분비내과 방문하여 검사 시행하였으나 이상소견 보이지 않음. 그 이후 지속적으로 환자 intermittent sweating, generalized weakness 있어서 저혈당 의심하여서 자가 혈당 측정하여 주로 오전 10 시에 상기 증상시 46~49 mg/dL 보임. 저혈당에 관하여 정밀 검사 위해 입원함

Past medical history HTN/DM/TB/hepatitis (-/-/-/-) dyslipidemia : simvastatin 20mg qd (3 년 전부터 복용 ) HRT : tibolone 2.5mg qd (5 년 전부터 복용, 약한달 전 hold) op. history : hystectomy – 7 yrs ago, due to uterine myoma Family history Personal history alcohol : (-) smoking : (-) MI, DM DM

Review of systems General fatigue(-) fever(-) chill(-) Wt. gain(+/-) ; 58kg (6~7 kg during 3 years) E & ENT visual disturbance(-) diplopia(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) cyanosis(-) Cardiac angina(-) orthopnea(-) palpitation(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain (-) Renal dysuria(-) hematuria(-) polyuria(-) Musculoskeletal myalgia(-) claudication (-) weakness (-)

Physical examination V/S 120/80 mmHg – 84/min – 20/min – 36.5 ℃ B.W) 58kg Height) 153cm BMI) 24.78kg/m 2 General Alert consciousness not so ill-looking Head & neck No cervical mass, No thyroid enlargement Eyes/ENT Isocoric pupil with PLR(++/++) Pinkish conjunctivae Clear sclerae Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft and flat abdomen No tenderness or rebound tenderness Back/extremity CVA tenderness(-/-) Pretibial pitting edema(-/-)

Impression #1. hypoglycemia reactive hypoglycemia r/o insulinoma r/o non-Beta cell tumor #2. post-memopausal state with tibolon medication #3. dyslipidemia with HMG-CoA reductase inhibitors medication

Diagnostic & Therapeutic plan #1. hypoglycemia OGTT 72 Hour fasting test abdominal CT #2. post-menopausal state with tibolon medication FSH, LH level check #3. dyslipidemia with HMG-CoA reductase inhibitors medication lipid profile check

ECG

Chest PA

Laboratory Finding I CBC/DC 5840/mm g/dL – 48.0 % - 242X10 3 / ㎣ (Seg %) Chemistry T-/D-bilirubin 0.72/0.08 mg/dL ( mg/dL) AST/ALT 44/63 U/L (<40/<40 U/L) ALP/GGT 23/210 U/L (39-117/<50 U/L) Pro/ALB 5.8/3.2 g/dL ( / g/dL) Glucose 91mg/dL (fasting:<100 mg/dL) BUN/Cr 14/0.8 mg/dL (8-23/ mg/dL) Na/K/Cl 140/4.1/108 mmol/L ( / / mmol/L) T-cholesterol 161 mg/dL (<200 mg/dL) LDL/HDL 100/34 mg/dL( 40mg/dL) TG178mg/dL (<150 mg/dL)

Laboratory Finding II Urinalysis WBC ; / HPF RBC ; / HPF protein ; (-) ketone ; (-) T3 ; 144 dg/dl (80~200 ng/dL) free T4 ; 0.84 ng/dl ( 0.77~1.94 ng/dl) TSH ; 2.19 (0.3~4.0 u/ml) E2 ;30.5 pg/ml Prog ;0.41 ng/ml FSH;43.4mIU/ml (1.7~8.5 mIU/ml) LH ; 22.7mIU/ml (2~15.4 mIU/ml)

Abdominal CT (06-1-6)

Glucose level (06-1-6) (no medication) Hypoglycemic Sxstop

Insulin level (06-1-6) (no medication)

C-peptide level (06-1-6) (no medication)

Final diagnosis #1. impaired glucose tolerance reactive hypoglycemia #2. post-menopausal state #3. dyslipidemia lipid profile check

Glucose level ( ) (nateglinide 60mg po 와 75g glucose 동시 투여 ) Hypoglycemic Sx stop

Insulin level ( ) (nateglinide 60mg po 와 75g glucose 동시 투여 )

C-peptide level ( ) (nateglinide 60mg po 와 75g glucose 동시 투여 )

GMT check ( ) (nateglinide 120mg po 식사 10 분전 동시 투여 ) No glycemic symptom