1. 종양혈액 내과 Case presentation 1

2. 12271252 송 O 석 (M/72) adm. date: 2013.03.29 Adm via ER C.C) 혈뇨 o/s) remote: 내원 10 일전 recent: 내원 전날 P.I) 상기 72 세 남자환자 약 10 일 전 친구들과 과음 후 복부 부딪히면서 넘어진 이후로 혈뇨 있다가 없어 졌다고 함. 내원 전날부터 검은변 나오고 혈 뇨 다시 시작되었으며, 내원 당일 혈뇨 심해지며 혼자 일어서지도 못할 정도로 전신 쇠약감 있어 응급실 내원함.

3. PMHx) –HTN/DM/TB/hepatitis (+/-/-/-) - for 3 years –Insomnia and dementia (+) - for 3 years –OP history (+) - traumatic SDH s/p Burr hole trephination (2006) –Drug history (+) : 한약 (-), illegal drugs (-) PHx) –Alcohol (+) - until 10 days ago ( 소주, 막걸리 ) - 소주 1-2 병 / 2-3 times a week –Smoking (-) - ex-smoker of 40 pack-years FHx) –Unremarkable HTN medicationNP medication Amlodipine (5mg)Trazodone (25mg) Diazepam (5mg) Donepezil (5mg)

4. Review of Systems General: fever (-), chills (-), weight loss (-) generalized weakness (+) Skin: rash (-), itching (-), petechiae (-), bruises (-) HEENT: headache (-), rhinorrhea (-), sore throat(-), hearing loss (-), gum bleeding (-) Chest: c/s/r (-/-/-), dyspnea(-), hemoptysis (-) Cardiac: chest pain (-), palpitation (-), DOE (-) GI: Epigastric pain (-), abdominal pain (-) A/N/V/D/C (+/-/-/-/-), hematochezia/melena (-/+), GU: dysuria(-), urgency(-), frequency (-), hematuria(+), flank pain (-/+), hematuria (+) Musculoskeletal: arthalgia (-), edema (-), stiffness (-), back pain (-) Nerve system: dizziness (-)

5. Physical Examinations V/S: 110/60mmHg – 88/min- 19/min – 36°C Height: 161cm / Weight: 58kg (BMI: 22.4kg/m 2 ) General : alert, acutely ill-looking appearance Skin: rash (-), pigmentation(-), petechiae (-), pale-looking HEENT: isocoric pupil with PLR (++/++) no palpable neck mass, NVE (-), LNE(-) white sclera, pale 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 (-/+)

6. Physical Examinations Neurology –Motor –Sensory pain & temperature vibration & proprioception Back & Extremities: CVA Td(-/-) Pretibial pitting edema (-/-) Joint swelling (-) Joint tenderness (-) Gross deformities (-) VV VV 100

7. Initial Lab Findings (13.03.29) CBC/DC) 8760/mm² - 9.6 g/dl – 27% - 307K (seg. 86.1%) Chemistry ) TB/DB0.25/0.09 mg/dL BUN/Cr 27/1.4 mg/dL Prot/alb6.3/3.6 g/dL Na/K/Cl134/4.4/102 mg/dL AST/ALT26/16 IU/L Ca/P/Mg8.6/3.1/2.4 mg/dL ALP/GGT52/12 IU/L Uric acid/LD 7.8/461 mg/dL CRP 2.04 mg/dL ESR 27 mm/hr aPTT153.4 s PT/PT INR >120 s / > 33 U/A) RBC many/HP WBC many/HP Ketone (+) pH 5.0 Protein (+++) Glucose (++++) Leukocytes(++) Nitrite(+) FeNa: 1.65% FeBUN: 11%

8. Chest X-ray (2013.03.29)

9. K.U.B (2013.03.29)

10. ECG (2013.03.29)

11. Initial Assessments #1 #1. Gross hematuria #2. Melena #3. Anemia #4. AKI, intrinsic type #5. Marked prolonged aPTT/PT #6. HTN, known #7. Insomnia, known #8. Dementia, known Bleeding tendency d/t acquired coagulopathy

12. Initial Assessments #2 #1. Gross hematuria #2. Melena #3. Anemia #4. AKI, intrinsic type #5. Marked prolonged aPTT/PT #6. HTN, known #7. Insomnia, known #8. Dementia, known Trauma GU malignancy Ureter/kidney stone UTI, glomerular disease

13. #1. Gross hematuria #2. Melena #3. Anemia #5. Marked prolonged aPTT/PT Assessment ) acquired coagulation factor deficiency, more likely d/t drug intoxication, most likely: Illicit drugs surreptitious administration of warfarin, heparin, anticoagulants, inhibitors of prothrombin /fibrinogen /factor V or X inhibitors of vitamin K dependent factors 한약 Severe vitamin K deficiency DIC, unlikely Liver disease. unlikely r/o congenital coagulopathy, least likely Diagnostic & Therapeutic Plans #1

14. #1. Gross hematuria #2. Melena #3. Anemia #5. Marked prolonged aPTT/PT Diagnostic Plan) 1.History taking again! : drugs, family hx, suicidal attempts etc 2.Anemia study: Vit B12, recticulocyte, TIBC, FOB, PB smear, folate, ferritin, serum iron 3.DIC lab: FDP, anti-thrombin III, d-dimer, fibrinogen, protein C&S 4.Mixing test (PT, aPTT) 5.Vitamin K serum level, PIVKA II, Vitamin K dependent factors titer 6.Gastroscopy Therapeutic Plan) Vitamin K + FFP transfusion Consider endoscopy and endoscopic intervention Treat according to etiology

15. #1. Gross hematuria #3. Anemia #4. AKI, intrinsic type Assessment ) Abdominal trauma c obstructive uropathy and anemia d/t bleeding r/o drug induced acute tubular injury d/t renal tubular obstruction r/o genitourinary malignancy (RCC, bladder cancer) r/o urinary stone c hydronephrosis r/o urinary tract infection r/o nephritic syndrome (RPGN, MPGN, autoimmune diseases such as SLE) Diagnostic & Therapeutic Plans #2

16. #1. Gross hematuria #3. Anemia #4. AKI, intrinsic type Diagnostic plan) 1.U/A, 24h urine collection, urine culture 2.Serology: Complements (C3, C4, CH50), IgG/A/G/E, ANA, ANCA 3.Abdomen imaging: USG or CT 4.Renal biopsy, if necessary Therapeutic plan) Hematuria catheter insertion Transfusion if needed Correcting underlying cause Diagnostic & therapeutic plans

17. #6. HTN, known #7. Insomnia, known #8. Dementia, known Plan) self medication 유지 Diagnostic & Therapeutic Plans #3

18. Clinical Course

19. Abdomen CT (2013.03.30)

20. Vit B12 : 560.1 pg/mL Folate : 3.7 ng/mL Ferritin : 62.0 ng/mL Recticulocyte : 1.62% TIBC : 221 ug/dL Serum iron : 80 ug/dL PB smear Normocytic normochromic RBCs Mildly increased WBC count with neutrophilia Anemia study (2013.03.29)

21. FDP : 4.00ug/mL Anti-thrombin III : 0.352g/L D-dimer : 1.05ug/mL Fibrinogen : 285mg/dL DIC lab (2013.03.29)

22. Gastroscopy (2013.03.30)

23. Mixing test (2013.03.30) Result PT18.4 1:1 mixing PT14.4 aPTT54.0 1:1 mixing aPTT38.7

24. PIVKA II : > 75000 Factor II : 28% Factor VII : 3% Factor V : 110% Factor X : 22% Potein C activity : 26% Protein S activity : 12% Vitamin K related factors(2013.03.30)

25. C3 : 83.6mg/dL C4 : 19.7mg/dL IgG : 943mg/dL IgA : 181mg/dL IgM : 86.8mg/dL IgE : 184IU/mL ANA : Non-reactive P/C-ANCA : negative Brodifacoum 검사 -> pending Serologic Tests (2013.03.30)

26. Overview 3/29 4/104/13 4/18 Abd CT Vitamin K I.V 10mg q 8 hrs Vitamin K p.o 50mg t.i.d FFP 8 pints/day FFP 8 pints/day 18 1.5 2 1.06 39.7 EGDD/COPD Vitamin K I.V 5mg q 8 hrs 4/3 5.45 6.75 1.37 63.9 82.4 40.1 Vitamin K I. V 5mg q 12 hrs FFP 6 pints/day FFP 6 pints/day Initial: 153.4 Initial: >33 Vit K 10mg 2.1 1.0

27. Final Diagnosis #1. Vitamin K dependent coagulation factors deficiency a/w hematuria (triggered by trauma to the abdomen) a/w remote GI bleeding a/w anemia d/t bleeding #2. AKI d/t acute tubular injury, resolved #3. HTN, known #4. Insomnia, known #5. Dementia, known