1. Case presentation 2
종양혈액 내과

2. 전O 수(M/52) adm. date:
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…

3. 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

4. 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

5. 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

6. 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

7. 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 / HPF WBC 0-1 / HPF

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

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

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

11. 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

12. 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

13. 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

14. 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

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

16. Clinical Course

17. 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

18. 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

19. 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

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

21. Brodifacoum level : Positive

22. Drug interaction 22

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