R2 박지나 내분비 대사 내과 R2 박지나 CASE CONFERENCE

이 O 승 M/35 Adm C.C.) Rt hip pain o/s : 내원일 14 시경 P. I.) M/35   6 년전 우측 요로 결석으로 이대 목동 병원에서 체외충격파쇄석술 받은 후 02 년, 04 년 2 회 재발되어 개인 비뇨기과 병원에서 체외충격파쇄석술 시 행.   3-4 년 전부터 자주 피로한 증세 있었으며 운동 시간도 감소하였던 중, 04 년 낚시여행 중에 자갈밭에서 넘어져 Rt Quadriceps muscle rupture 되어 보조기 착용 후 지내다 집에서 다시 넘어져 Rt humerus fracture 및 Lt Quadriceps muscle rupture 생김.   내원일 오후 14 시경 빙판길에서 미끄러져 Rt hip pain 으로 응급실 내원, 수술 위해 정형외과 입원함

PMHx) DM(-) HTN(+) Pulmonary Tb (-) Hepatitis(-) OP Hx(-) Allergy(-) Rt ureter stone : 00, 02, 04 년 3 회 ESWL 시행 PHx) alcohol (+) 소주 1 병 /1 회, 1 주 1 회 smoking(+) 20 Packs/years

Family history DM DM CVA 로 사망 Behcet’s disease

Review of system General fatigue(+) fever(-)chills(-) Skin rash(-) pigmentation(-) Head & neck headache(-)dizziness(-)neck pain(-) Eye & ENT visual disturbance(-) hearing loss(-) Breast pain(-)lump(-) discharge(-) Respiatory cough(-) sputum(-)dyspnea(-) Cardiac angina(-)orthopnea(-)palpiation(-) Gastointestinal anorexia (+) nausea(-) vomiting(-) diarrhea(-) constipaition(-) abdominal pain(-)

Renal & urinary dysuria(-)frequency(-) Musculoskeletal low back pain(-) no knee pain(-) muscle cramps(-) Rt hip pain(+) Endocrine Weight gain or loss (-) thirsty(-)polydipsia(-) polyuria(-) heat intolerance(-)

Physical examination BW 78 kg Ht 175cm BMI : 24.5kg/m2 V/S120/80 mmHg- 70/min- 20/min ℃ General Alert consciousnessAcute ill apearance Skin No striae No bruisinessskin turgor ; intact Head & neck Normocephaly No thyroid gland enlargement No palpable mass

Eye & ENT Isocoric pupils with pupil light reflex(++/++) clear conjuctiva, an-icteric sclerae Throat injection(-) Chest Clear breathing sound without crackle or wheezing Regular heart beat without murmur Abdomen Normoactive bowel sound Soft & flat abdomen Tenderness/Rebound tenderness(-/-)

Back & extremities CVA tenderness(-/-) Pretibial pitting edema(-/-) Rt hip tenderness(+) open wound(-) LOM(+) Neurology facial palsy(-) DTR(+/+) mortorsensory v v IIII

Laboratory findings CBC/DC 6090/mm g/d4L – 61.3 % - 252X10 3 / ㎣ (Seg. 55 %) Chemistry T-/D-bilirubin 1.11/0.22 mg2/dL ( mg/dL) T-cholesterol 211 mg/dL(<200 mg/dL) AST/ALT 39/51 U/L(<40/<40 U/L) Pro/ALB 6.8/4.2 g/dL(5.8~8.0/ g/dL) BUN/Cr 11/0.8 mg/dL(8-23/ mg/dL) Na/K/Cl 137/3.6/100 mmol/L ( / / mmol/L) Ca/P/Mg12.0/1.9mg/dL ( / mg/dL) Glucose 121 mg/dL ABGA –

EKG

Chest PA

Hip AP/LAT

Initial problem list 1.Rt hip pain 2.Hypercalcemia3.Osteoporosis Initial assessment 1.Rt Femoral subtrochanteric fracture 2.Hypercalcemia d/t hyperparathyroidism d/t hyperparathyroidism d/t hidden malignancy d/t hidden malignancy3.osteoporosis

Diagnostic plan   Hypercalcemia and Osteoporosis Serum Ca, Phosohorus, PTH 24h-urine Ca, P,Cr,CrCl BMD Spine AP/LAT L- Spine AP/LAT Neck sono,Parathyroid scan Neck sono,Parathyroid scan Abdomen sono Abdomen sono

Endocrinologic Lab. findings PTH : (13~54 pg/mL) PTH : (13~54 pg/mL)24h-urine Ca: mg/day(100~240 mg/day) Ca:415 mg/day(100~240 mg/day) Creatinine: 1003 mg/day (800~1800 mg/day) CrCl: ml/min (70~157 ml/min) CrCl: ml/min (70~157 ml/min)

L-SPINE AP

KUB(02.5 월 )

Both knee AP(04.1 월 )

Neck and thyroid sono

PTH scan

Abdominal sono

Final diagnosis Primary hyperparathyroidism d/t parathyroid adenoma

Therapeutic plan  Parathyroidectomy Ix : serum Ca 1.0 Ix : serum Ca hr urinary Ca 400 mg < 24hr urinary Ca 400 mg < CrCl 30% CrCl 30% BMD T-score <-2.5 BMD T-score <-2.5 Age 50< Age 50<