1. 1 M G R Endocrinology 오승준 교수님 /R1 조병현

2. 2 11853316 한 O 석 F/72 admission 06-8-20 C.C) uncontrolled DM P. I) 3 년 전 type 2 DM 진단 받은 후 개인 병원에서 경구 혈 당 강하제 (Glimepride, Voglibose) 로 조절. 내원 2 주전 오 른쪽 얼굴에 대상포진 발생하여 Methylprednisolone 포함 한 약을 복용 후 혈당 조절 되지 않아 혈당 조절 및 당뇨 합병 증 검사 위해 입원.

3. 3 PMHx) DM/HTN/pul.Tb/hepatitis(+/-/-/-) DM : Glimepride 3mg, Voglibose 0.3mg Osteoarthritis (+) Old L-spine (L5) compression Fx. OP.Hx(+) : Cataract op. both - 2 년 전 Drug Hx : Phenytoin, Amitriptyline, hydroxyzine Cimetidine, Gabapetine  일주일 간 복용 FHx.) None PHx.) Alcohol(-) Smoking(-)

4. 4 ROS/PE  General fatigue(+)  G.I A/N/V/D/C(+/-/-/-/-) abdomial pain(-)  Nervous syncope(+) : 내원 4 일 전 5 분간 LOC (+) seizure(-) dizziness(-) tremor(-)  G/A chronically ill looking appearance  Skin rash with crust formation – Rt. face  Thorax clear breathing sound without rale regular heart beat without murmur  Abd. soft & flat abdomen normoactive bowel sounds

5. 5 Laboratory finding CBC/DC 4390/mm² -11.7 g/dl-32.4 %-71K (seg 67.1%) Chemistry TB/DB 1.23/0.56 mg/dl AST/ALT 137/143 U/L ALP/GGT 67/334 U/L Prot./alb 5.3/2.3 g/dl LD/CK 533/74 U/L BUN/Cr 7/0.7 mg/dl Ca/Mg/P/uric acid 7.6/1.9/2.1/2.5 mg/dl Glucose 342 mg/dl Na/K /Cl 133/2.7/103 mmol/l UA RBC 2-4/HPF WBC 10-29/HPF Osmolality serum/urine 286/311 mOSM/Kg Spot urine Na/K/Cl 35/4/36 mmol/l Cr 16 mg/dl

6. 6 Laboratory finding  Anti-HAV IgM : Negative  HBsAg : Negative  HBcAb : Positive  HBsAb : Positive  Anti-HCV : Positive

7. 7 Chest PA

8. 8 ECG

9. 9 Impression 1. Type 2 DM 2. Chronic hepatitis C 3. Syncope R/O Hypoglycemia R/O Transient ischemic attack 4. Hypokalemia with HTN R/O Primary hyperaldosteronism 5. Old L-spine(L5) compression fracture 6. Asymptomatic pyuria

10. 10 Diagnostic & Therapeutic plan 1. Type 2 DM C-peptide DM complication study Multiple daily injection Lantus 12U Humalog 10U/10U/10U 2. Chronic hepatitis C HCV RT-PCR Abdominal sono 3. Syncope Brain MRI with diffusion scan

11. 11 Diagnostic & Therapeutic plan 4. Hypokalemia with HTN R/O Primary hyperaldosteronism Lasix 복용 유무 확인 Plasma renin activity Serum Aldosterone Saline loading test or Lasix stimulation test

12. 12 Diagnostic & Therapeutic plan 5. Old L-spine(L5) compression fracture L-spine AP / Lateral BMD(Bone mineral density) 6. Asymptomatic pyuria U/A F/U Urine culture

13. 13 Brain MRI (06.9.6)

14. 14 Pituitary function test(06.9.8) GHFSHLH 26.3 ng/ml92.9 mIU/ml36.4 mIU/ml T3FT4TSH 136 ng/dL1.14 ng/dL8.28 mU/L ACTHCortisol 23.9 pg/mL/10.9 pg/mL16.9 ug/dl 8.0 ug/dl

15. 15 Final diagnosis 1. Type 2 DM 2. Chronic hepatitis C 3. Pituitary apoplexy 4. Primary hyperaldosteronism 5. Old L-spine(L5) compression fracture 6. Asymptomatic pyuria

16. 16 Brain MRI (06.11.20)

17. 17 11867443 박 O 홍 M/52 admission 06-10-13 C.C) Headache o/s) 내원 4 일전 P. I) 평소 특이 병력 없던 자로 내원 4 일전부터 발생한 두통 및 visual disturbance 를 주소로 내원 PMHx) DM/HTN/pul.Tb/hepatitis(-/-/-/-) FHx.) None PHx.) Alcohol(+):social Smoking(-)

18. 18 ROS/PE  General fatigue(-)  H&N headache(+) diplopia(+)  visual disturbance(+)  G.I A/N/V/D/C(-/-/-/-/-) abdomial pain(-)  Nervous syncope(-) seizure(-) dizziness(-)  G/A alert mental status  acutely ill looking appearance  Eye&ENT isocoric pupil c PLR(++/++) EOM:full  Thorax regular heart beat without murmur  Abd. soft & flat abdomen

19. 19 Laboratory finding CBC/DC 4750/mm² -14.2 g/dl-43.4 %-219K (seg 47.3%) Chemistry TB/DB 0.55/0.13 mg/dl AST/ALT 55/25 U/L ALP/GGT 47/17 U/L Prot./alb 6.1/3.0 g/dl BUN/Cr 16/0.8 mg/dl Ca/P/uric acid 8.2/3.7/1.4 mg/dl Glucose 492 mg/dl Na/K /Cl 136/3.8/103 mmol/l UA RBC 2-4/HPF WBC 0~1/HPF

20. 20 Chest PA

21. 21 ECG

22. 22 Impression 1. Headache with diplopia R/O pituitary mass R/O tension headache

23. 23 Diagnostic & Therapeutic plan 1. Headache with diplopia R/O pituitary mass R/O tension headache Brain CT

24. 24 Brain CT (06.10.13)

25. 25 Sella MRI (06.10.15)

26. 26 Pituitary function test (06.10.13) GHFSHLH 0.5 ng/ml2.4 mIU/ml0.7 mIU/ml T3T4TSH 103 ng/dL6.1 ng/dL0.7 mU/L ACTHCortisol 7.4 pg/mL24 ug/dl

27. 27 Clinical course (HD #3) 1. Headache with diplopia R/O pituitary mass R/O tension headache S&O) headache(+) diplopia(+) Brain MRI : Suggestive of hemorrhagic pituitary adenoma A) Pituitary apoplexy P) OPH consult for visual field ENT consult for operation (TSA) IE consult for management  pituitary function test operation (TSA)

28. 28 Final diagnosis  Pituitary apoplexy

29. 29 Pituitary function test (06.10.17) -postop- GHFSHLH 0.1 ng/ml1.9 mIU/ml0.4 mIU/ml T3T4TSH 55 ng/dL4.7 ng/dL0.36 mU/L ACTHCortisol 19.6 pg/mL5.6 ug/dl

30. 30 Postop Sella CT (06.10.17)

31. 31 Postop Sella MRI (06.11.2)

32. 32 10860514 우 O 건 M/53 admission 06-4-9 C.C) Rt. arm tingling & weakness P.I) 내원 4~5 일전 글씨 쓰는 데 갑자기 Rt 3~5th finger tingling 발생, shoulder 까지 proximal 로 진행후 weakness 있었으나 특별한 Mx 없이 지내다 내원 20 분전 같은 증상 발생하며 전신 강직증상 보여 ER visit PMHx) DM/HTN/pul.Tb/hepatitis(-/-/-/-) Op Hx(+):Rt 4,5 th finger op(5 th amputation) FHx.) None PHx.) Smoking(+):15pack-year Alcohol(-)

33. 33 ROS/PE  General fatigue(-)  H&N headache(-) visual disturbance(-)  G.I A/N/V/D/C(-/-/-/-/-) abdomial pain(-)  Nervous syncope(-) seizure(-) dizziness(-)  numbness(+):Rt. side  G/A alert mental status acutely ill looking appearance  Eye&ENT isocoriv pupil c PLR(++/++) EOM:full  Neurology motor V V sensory V V V V V V

34. 34 Laboratory finding CBC/DC 10460/mm² -15.5 g/dl-47.6 %-238K (seg 43.3%) Chemistry TB/DB 0.55/0.12 mg/dl AST/ALT 17/16 U/L ALP/GGT 102/21 U/L Prot./alb 7.3/4.2 g/dl BUN/Cr 18/0.9 mg/dl Ca/P/uric acid 8.1/2.8/5.0 mg/dl Glucose 233 mg/dl Na/K /Cl 141/4.2/101 mmol/l UA RBC 0~1/HPF WBC 0~1/HPF

35. 35 Chest PA

36. 36 ECG

37. 37 Brain CT (06.4.9)

38. 38 Impression 1. R/O Cb infarction R/O C-spine radiculopathy R/O segmental myoclonus 2. Seizure, partial 3. Type 2 DM

39. 39 Diagnostic & Therapeutic plan 1. R/O Cb infarction R/O C-spine radiculopathy R/O segmental myoclonus Brain MRI Antiplatelet EMG, EEG

40. 40 Diagnostic & Therapeutic plan 2. Seizure, partial Oxcarbazepine 3. Type 2 DM DM education Gliclazide(160mg qd)+metformin(500mg tid)

41. 41 Brain MRI (06.4.12)

42. 42 Sella MRI (06.4.15)

43. 43 Final diagnosis 1. Cb infarction 2. Seizure, partial 3. T 2 DM 4. Pituitary apoplexy

44. 44 Triple stimulation test(06.4.16) 0306090120 ACTH38.8454.3391.9158.372.8 GH0.15.84.63.72.6 Cortisol22.632.738.735.242.6 FSH8.012.015.016.510.9 LH8.124.228.721.718.2 PRL2.711.420.313.17.7 TSH1.713.79.86.94.6