Case presentation 2 종양혈액 내과

12058879 전O 수(M/52) adm. date: 2009.07.21 C.C) 혈뇨 o/s) 1개월 전 P.I) 52세 남자. 1개월 전 무좀으로 2주간 플루코나졸 복용중 갑자기 발생한 혈뇨로 의정부 성모병원 방문하여 응고인자장애 진단하 보존적 치료중 복부통증 발생하였으며 추가로 시행한 복부 컴퓨터 단층촬영상 혈복강 진단되어 수술후 환자 및 보호자 원하여 본원으로 전원됨. 외부에서 CT 찍은 것들 등 다 뺍니다…

PMHx) PHx) FHx) HTN/DM/TB/hepatitis (-/-/-/-) OP history (+) Small bowel segmentectomy d/t hemoperitoneum, 2009/6/29 Drug history (+) : Fluconazole p.o. for 2 weeks PHx) Alcohol (-) Smoking (-) FHx) Unremarkable Eperisone hydrochloride

Review of Systems General : Fever (-), chills (-), weight loss (-) Skin : Itching (-), rash (-) HEENT : Headache (-), sore throat(-) Chest : C/S/R (-/-/-), dyspnea (-) Cardiac: Chest pain (-), palpitation (-), DOE (-) GI: Abdominal pain (-), A/N/V/D/C (-/-/-/-/-), hematochezia (-), melena (-/-) GU: Frequency (-), hematuria(-) Musculoskeletal : LBP(-), edema (-) Nerve system: Dizziness (-), sensory loss(-) Gum bleeding, petechiae, bruises 없었음! Blood tinged sputum등은 다 뺍니다…없었던 걸로

Physical Examinations V/S: 130/90mmHg – 76/min - 16/min – 36.5 ℃ General : alert, acutely ill-looking appearance Skin: rash (-), pigmentation(-), petechiae (-) HEENT: isocoric pupil with PLR (++/++) no palpable neck mass , NVE (-), LNE(-) white sclera, red conjunctiva Chest: Symmetric chest expansion Clear breathing sound without rales/crackles Regular heart beat without murmur Abdomen: Soft and flat abdomen Normoactive bowel sound, DRE (-) Td / rTd (-/-), MG (-), CVA td (-/-) ROM Motor, sensory 추가

Physical Examinations Back & Extremities: CVA Td(-/-) Pretibial pitting edema (-/-) Joint swelling (-) Joint tenderness (-) Gross deformities (-) Neurology Motor Sensory pain & temperature vibration & proprioception V ROM Motor, sensory 추가 100

Initial lab finding (2009.07.21) CBC/DC) 5050/mm² - 12g/dl – 35.2% - 249K (seg. 47.7%) aPTT 87.8 sec PT INR 5.20 Chemistry ) TB/DB 0.53/0.15mg/dl BUN/Cr 19/0.9 mg/dl Prot/alb 7.7/4.4 g/dL Na/K/Cl 140/3.8/101 mg/dl AST/ALT 29/25 IU/L Ca/P/Mg 9.1/3.5/2.1 mg/dL ALP/GGT 65/44 IU/L Uric acid 3.6 mg/dL CRP < 0.5 mg/dL U/A) RBC 0-1 / HPF WBC 0-1 / HPF

Chest X-ray (2009.07.21) No active lung lesion. Heart is normal in size.

ECG (2009.07.21) .Normal sinus rhythm PR 90/min -> tachycardia 없었음!

Initial Assessments #1 Problem list #1. Pronlonged PT/aPTT #2. Hematuria #3. Hemoperitoneum #4. Conjuctival hemorrhage #5. Tinea pedis

d/t acquired coagulopathy d/t acquired coagulopathy Initial Assessments #2 #1. Prolonged PT/aPTT #2. Hematuria #3. Hemoperitoneum #4. Conjuctival hemorrhage #5. Tinea pedis Bleeding tendency d/t acquired coagulopathy Bleeding tendency d/t acquired coagulopathy

Diagnostic & therapeutic plans #1. Increased bleeding tendency Assessment ) r/o acquired coagulation factor deficiency, more likely r/o d/t vitamin K dependent factor deficiency/inhibition r/o d/t inhibitors of coagulation factors r/o d/t liver disease r/o d/t disseminated intravascular coagulation (DIC) r/o congenital coagulopathy, less likely Diagnostic plan) PT, INR, aPTT, mixing test LFT, Abd. sono / CT FDPs, anti-thrombin III, d-dimer, fibrinogen CBC, PB smear, Vitamin K dependent factors titer Therapeutic plan) FFP supply, Correcting underlying cause

Diagnostic & therapeutic plans #2. Hematuria Assessment ) r/o d/t increased bleeding tendency, more likely r/o glomerular disease r/o genitourinary malignancy r/o genitourinary stone / hydronephrosis r/o urinary tract infection Diagnostic plan) serologic test, AP sono, urine cytology urine culture, IVP, U/A f/u Therapeutic plan) Hematuria catheter insertion Correcting underlying cause Transfusion if needed

Diagnostic & therapeutic plans #3. History of hemoperitoneum Assessment ) r/o d/t increased bleeding tendency r/o d/t trauma Plan) History taking CBC f/u #4 Subconjuctival hemorrhage OPH consultation, observation

Diagnostic & therapeutic plans #5. Tinea pedis, known Plan) Fluconazole hold

Clinical Course

Clinical course D/C 7/21 7/23 7/24 7/31 8/7 FFP 4 pints/day FFP Vitamin K p.o 5mg 2T bid Vitamin K p.o 5mg 2T bid

Hematologic evaluation Factor Ab VIII (-) Factor Ab IX (-) Factor assay VIII : 172% Factor assay V : 69% Factor assay IX : 4% Factor assay X : 6% Protein C activity : 16% Protein S activity : 19% Factor VII : 8% Factor II : 5% Vitamin K dependent

Hematologic evaluation PB smear WBC : Normal in number RBC : Normocytic normochromic PLT : Normal in number Mixing test Result PT 56.1 1:1 mixing PT 14.7 aPTT 96.2 1:1 mixing aPTT 38.6

SEROLOGIC EVALUATION RA factor < 10 IU/mL C-ANCA : negative P-ANCA : negative ANA : non-reactive

Brodifacoum level : Positive

Drug interaction 22

Final Diagnosis Bleeding tendency d/t brodifacoum intoxication of unknown etiology