1. 복부 통증을 주소로 내원한 40 세 남자 소화기내과 R 1 오치혁 / Prof. 동석호 2010.10.14 MGR

2. 12023942 오 O 명 (M/40) adm. : 10. 7. 17 Chief Complaint –Epigastric pain o/s> 내원 1 일전 Present illness – 약 6 년전에 KTP donor 로 Lt. nephrectomy, alcoholic liver disease( 본원 IG prof. 동석호 f/u 중 ), Dyslipidemia( 본원 IN prof. 임 천규 f/u 중 ) Hx 있는 40 세 남환으로 평소 특이증세 없었으나 내원 1 일전 저녁 9 시경부터 epigastric pain, nausea 발생, 점점 심해져서 응급실 내원 History

3. Past Medical History DM/HTN/TBc/Hepatitis(-/-/-/-) Alcoholic liver disease KHMC IG 동석호 교수님 OPD f/u 2010. 년 7 월 8 일 ~ Dyslipidemia KHMC IN 임천규 교수님 OPD f/u 2009 년 1 월 ~ Fluvastatin 복용중 Op Hx(+) –Lt. nephrectomy 6 년전, 동생에게 donor, 이대병원 –Appentectomy 약 10 년전

4. Personal History Alcohol : 현재 음주 – 소주 1~2 병씩, 주 3~4 회, 약 2 주 전부터 금주 Smoking : 과거 흡연 – 약 8 년전 stop Drug Hx : 벚나무 다린 물 ( 내원 3 일전부터 복용 ) Family History 동생 : ESRD d/t MCD s/p KTP

5. Review of System (1) 1. General Generalized weakness(-) Fever(-) Chill(-) Myalgia(-)Weight change(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(-) Visual disturbance(-) Otalgia(-) Otorrhea(-)PND(-)Nasal obstruction(-) Rhinorrhea(-)Sore throat(-)Swallowing difficulty(-) 4. Respiratory Dyspnea(-) Cough(-)Sputum(+)Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)DOE(-) Palpitation(-)

6. 6. Abdominal A/N/V/D/C(-/+/+/-/-) Dysphagia(-) Bowel habit change(-) Abd. pain(+) : Epigastric, RUQ Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(-) Swelling(-) Tenderness(-) Backpain(-) Myalgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Review of System (2)

7. Physical Examination (1) Height : 168 cm Weight : 80.5 kg BMI : 28.5 kg/m 2 Vital Sign : 100/70 mmHg - 78/min - 20/min - 36.6 ℃ 1. General appearance Alert consciousness Acutely-ill looking appearance 2. Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 3. E/ENT Isocoric pupil c PLR(++/++) Pinkish conjunctiva, Mildly icteric sclera Pharyngeal injection(-), PTH(-/-)

8. Physical Examination (2) 4. Chest Symmetric chest expansion Clear Breathing Sound without rale and wheezing Regular Heart Beat without ⓜ 5. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(+), Rebound Tenderness(-) Palpable mass(±), Hepatomegaly(+) : 2 fingers 6. Back&extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-) 7. Motor, sensory : intact

9. Initial Lab Finding 1.CBC/DC 10,700 / ㎕ - 15.1 g/ ㎗ - 46.1 % - 246,000 / ㎕ (seg : 67.3%) aPTT 47.2 sec PT INR 1.29 % 2.Chemistry TB / DB6.14 / 5.14 mg/ ㎗ BUN/Cr18 / 1.0 mg/dL Protein/Albumin5.9 / 3.1 g/ ㎗ Na/K/Cl 138 / 4.3 / 105 mEq/L AST/ALT76 / 19 U/L Ca/P/Mg 9.0 / 3.3 / 1.6 mg/dL ALP/rGT279 / 187 U/L Uric acid6.1 mg/dL Amylase/Lipase664 / 89 U/L CRP2.01 mg/dL 3.UA RBC 5~9 /HPF WBC 10~29 /HPF Blood - Protein 4+ Glucose ± Bilirubin 3+ Prev. lab2009/1/192010/7/8 T.B. / D.B.0.84 / 0.19 2.49 / AST / ALT33 / 3781 / 28 ALP / GGT76 / 217266 / 334 2009 년 1 월 FM OPD 시행 UA Protein ± IN OPD 에서 시행한 Spot Urine 43/127 mg/Cr (2010/06)

10. Initial Chest AP

11. Initial Simple Abdomen X-ray

12. Initial ECG

13. #1. Abdominal pain and nausea #2. Elevated LFT and pancreatic enzyme #3. Proteinuria #4. s/p Lt. nephrectomy(Kidney donor) Initial Problem Lists

14. #1. Abdominal pain and nausea #2. Elevated LFT and pancreatic enzyme → Acute pancreatitis d/t r/o CBD stone r/o Toxic hepatitis r/o Alcoholic hepatitis(alcoholic fatty liver) r/o Liver cirrhosis Diagnostic Plan> Abdominal CT, Abdominal SONO ERCP or MRCP, Lab f/u Therapeutic Plan> Hydration, TPN, NPO, 필요시 Antibiotics Protease inhibitor(Gabexate mesylate) Initial Assessment and Plan

15. #3. Proteinuria #4. s/p Lt. nephrectomy(Kidney donor) → Nephrotic syndrome r/o MCD r/o MPGN r/o FSGS r/o DN r/o Amyloidosis r/o Intermittent proteinuria Plan> UA f/u, Spot Urine check, 24hrs urine collection, UPEP, kidney SONO IN consult 시행 : 필요시 renal biopsy 고려 Initial Assessment and Plan

16. 7/16 Adm 7/17 Clinical course - 7/17 #1 입원 5hrs 후 : BP↓ (80/50), HR↓ (38~40 /min) Oliguria, elevated K(6.5) and Cr.(2.4)

17. S> –Severe Abdominal pain(+) 입원직후 :3 점 // 입원 약 5 시간 후 : 5 점 –Fever(-), Oliguria(+) O> – 입원 5 시간 후 V/S : 70/40 mmHg – 38 /min – 20 /min – 36 ℃ –ARF(Cr 1.0→2.6, eGFR 88→29, FENa 0.04, FEUr 9.96 ), Hyperkalemia(6.5) –Hypoxia – ABGA : 7.32 - 28.9 - 57.6 - 88.5% (RA) A> –Severe Acute Pancreatitis with Multiorgan failure d/t r/o biliary pancreatitis P> –Antibiotics : Carbapenem –ICU care –Supportive Mx for ARF –Echocardiography Progression Note - 7/17 #1

18. 7/167/187/17 Clinical Course - 7/18 #2 Adm Meropenem ICU care Hyperkalemia 교정, Hydration, Inotropics 110/60mmHg–70/min–20/min–36.8 ℃ Echocardiography 시 행 :EF=71%,E/E’=13.1

19. 7/167/187/197/20 Sono CT ERC P 7/17 Clinical Course - 7/20 #4 Meropenem ICU care Adm Abdominal SONO 시행 Abdominal CT 시행 ERCP 시행 : EST, CBD clearing Cr 2.8(7/19)→2.0(7/20), PT INR 1.56

20. HD #3 (2010.7.19) Abdominal SONO & HD #4 (2010.7.20) Abdominal CT

21. HD #4 (2010.7.20) ERCP

22. Ascites 7/167/187/197/207/217/22 ICU care Meropenem 7/17 Clinical Course - 7/22 #6 Sono CT ERC P Adm 일반 병실로 전실 Cr : 1.4, eGFR : 60 Abd. Distension d/t Ascites : Paracentesis

23. 7/167/187/197/207/217/227/237/24 ICU care Meropenem 7/17 Clinical Course - 7/24 #8 Axon+Metro Ascites Sono CT ERC P Adm EGD Hematemesis(+) : L-tube irr.(+), DRE(-) V/S stable, Hb : 13.7→12.8 EGD 시행 : delayed EST site bleeding

24. 7/167/187/197/207/217/227/237/247/257/26 ICU care Meropenem Axon+Metro 7/17 Clinical Course - 7/26 #10 Meropenem ICU care Ascites Sono CT ERC P Adm EGD ERC P CRRT Alert consciousness, V/S stable Urine↓/ General condition↓/ Jaundice↑ CRRT start, Liver Transplantation 고려 Ascites ↑↑

25. 7/167/187/197/207/217/227/237/247/257/267/27 ICU care Meropenem Axon+Metro 7/17 Clinical Course - 7/27 #11 Meropenem ICU care Ascites CRRT Sono CT ERC P Adm EGD ERC P Confusion – Hepatic encephalopathy INR 3.7 FFP transfusion Cr :3.5, eGFR : 20 (on CRRT)

26. S> –Abdominal pain(+), Abdominal distension(+) –Fever(-), Dyspnea(+) O> –Confusional consciousness(alert state 와 번갈아 가면서 나타남 ) –Paracentesis : mildly blood 양상으로 배액 –PT INR 3.7 : FFP –CRRT 시행중 A> –Fulminant hepatic failure( r/o Acute on Chronic liver disease) a/w hepatic encephalopathy, hepatorenal syndrome P> –CRRT 유지 –Liver transplantation (Cadever Donor Waiting) Progression Note - 7/27 #11

27. 7/167/187/197/207/217/227/237/247/257/267/27 ICU care Meropenem Axon+Metro 7/17 Clinical Course - 7/29 #13 Meropenem ICU care Ascites CRRT Sono CT ERC P Adm EGD ERC P Mental ↓ 7/287/29 LT Livertansplantation 시행 : from 영남대 Donor

28. HD#13 (2010.7.29) Liver Transplantation 시행

29. HD#13 (2010.7.29) Post-OP Pathologic finding

30. 7/167/187/197/207/217/227/237/247/257/267/277/287/29 7/30 ICU care Mental ↓ Meropenem Axon+MetroMeropenem Ascites 7/17 Clinical Course - 7/30 #14 CRRT Sono CT ERC P Adm EGD ERC P

31. Fulminant hepatic failure due to secondary amyloidosis Final Diagnosis