Download - IM4 Case Report 최 0 옥 M/52
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IM4 Case Report최 0 옥 M/52본과 3 학년 2007313075 손의영
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Chief Complain For Blood Sugar Level Control
No prominent Symptoms
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Present Illness 2003. 03 건강 검진에서 DM 발견 . 이후 경구 혈당 강하제로 BSL control
2007. 08 Insulin Start
이 후 계속적으로 insulin level 과 경구약을 증량 하였으나 BSL control 이 잘 이루어 지지 않음 2011. 03. 20 BSL control 위해 입원 함
(Multiple Diary Injection 고려 )
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Past Medical History 당뇨병 (+) 고혈압 (+)간염 (-) 결핵 (-)알레르기 (-) 항생제 알레르기 (-)
2010. 07. 23. Micro-Vascular Decompres-sion for
Hemifacial Spasm (NS)
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Family History 가족 중 당뇨 , 고혈압 환자 없음
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Social History Smoking 하루 2 갑 , 30 년 Alcohol 소주 2 병 , 일주일에 4~5 번
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Review of System – (1) GW/EF (-/-) weight loss (-)
poor oral intake(-) blurred vision(-)
night sweating(-)
Fever/Chill (-/-) Headache/Dizzi-ness(-/-)
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Review of System – (2) R/C/S (-/-/-) sore throat (-) oral pain(-) hemoptysis (-) dyspnea (-) sweat-
ing(-) chest pain (-) palpitation (-)
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Review of System – (3) abdominal pain (-) discomfort (-) A/N/V/D/C
(-/-/-/-/-) melena/hematochezia/hematemesis (-/-/-)
myalgia /arthralgia (-/-) easy bruisibility (-)
urinary Sx (+) : frequency
tingling sensation (-)
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Physical Examination – (1) 81.8kg 171.3cm BMI 27.8 Vital sign 168/105 – 70 – 20 – 36.0
General Appearance not so ill-looking Mental status alert Orientation well oriented
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Physical Examination – (2) Head & Neck
Anemic conjunctivae No
Icteric sclerae No
Dehydrated tongue No
Tonsilar Hypertrophy No
Pharyngeal Injection No
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Physical Examination – (3) Chest
Symmetric Chest Expansion
Regular heart beat, no murmur
Clear breathing sound at both lung
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Physical Examination – (4) Abdomen
Soft & Flat
Bowel sound Normoactive
Tenderness No
Rebound tenderness No
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Physical Examination – (5) Back & Extremity
CVAT No
Pitting Edema No
Skin lesion No
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Physical Examination – (6) Peripheral Neurological Test
Vibration scale 35/20
Temp sense +/+
Monofilament sense 10/10
Dorsalis pedis +/+
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Problem List #1. DM, poorly controlled #2. Mild overweight #3. Hypertension #4. HFS s/p MVD #5. Heavy Smoker #6. Alcoholics
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Assessment – 1st
I. #1, #3, #5, #6 R/O DM Neuropathy R/O DM Nephropathy R/O DM Retinopathy R/O Peripheral artery Disease
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Diagnostic plan CBC Chemistry Electrolyte Urinalysis Continuous Glucose
Monitoring
Chest X-ray (routine)
ANF
Diabetic vascular test Fundoscopy Carotid IMT CPT
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Lab – CBC WBC 5.88 x10³/μL
RBC 4.75 x10³/μL
Hb 15.1 g/dL Hct 44.4%
PLT 154,000/μL
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Lab – Chemistry (1) Protein 6.2 g/ ㎗ Albumin 4.3 g/ ㎗ Globulin 2 g/ ㎗ PT 13 sec 103% 0.98 INR
APTT 29.7 sec
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Lab – Chemistry (2) AST 31 U/l
ALT 37 U/l
ALP ▼ 48 U/l
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Lab – Chemistry (3) BUN 14.8 mg/dl Cr ▼ 0.61 mg/dl BUN & Cr ▲24.3
Estimated GFR 133.8 mL/min
Uric acid 4.9 mg/dl Ca 9.1 mg/dl P 3.6 mg/dl
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Lab – Chemistry (4) Glucose, fasting▲ 239 mg/dl
HbA1c 9.9 %
Insulin ▲ 80.5 uIU/ml
C-peptide 5.65 ng/ml
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Lab – Chemistry (5) Triglyceride 174 mg/dl
HDL-C 49 mg/dl
LDL-C 108 mg/dl
Free fatty acid ▲ 694 uEq/
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Lab – Electrolyte Na 143 mmol/ℓ
K 3.7 mmol/ℓ
Cl 102 mmol/ℓ
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Lab – Urinalysis Creatinine, urine 27.54 mg/dl
Microalbumin ▲ 11.45 mg/dl
ALB/Cr ratio, urine ▲ 415.76 ug/mgCr
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Lab – Glucose Poorly controlled
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Continuous Glucose MonitoringPoorly con-
trolled,(Especially Sat-
urday)
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Imaging – CXR Normal Heart Size No tracheal deviation No active lesion
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ANF
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ANF Early Autonomic dysfx.
I. 1/2 OR II. 1/3
Definite … I. 1/2 AND II. 2+/3
Severe … I. 1+/2 AND II. 2+/3
WNL All Normal
Early autonomic dysfunction
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Imaging – Fundoscopy No DM change
No microaneurysm No hard exudate No soft exudate No retinal hemorrhage No neovascularization
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Imaging – Carotid IMT Both common and internal carotid arteries
No Wall thickening, No PlaqueDistalCCA Bulb
ProximalICA
Right 0.54mm 0.45mm 0.37mm
Left 0.56mm 0.47mm 0.42mm
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Imaging – CPT Lt. peroneal nerve : normal
normal
Rt. Peroneal nerve Grade 7.00 의 mild hypoes-
thesia
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Imaging – EKG Normal Sinus Rhythm
LVH 없음Left Deviation ; Lead I (+) &
aVF (-)
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Imaging – Abdomen US Liver 의 크기와 모양은 정상이나 parenchymal echo가 전체적으로 증가되어 있음 . 내부에 뚜렷하게 그려지는 focal mass 없음 .
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Imaging – Abdomen US Left kidney 에 약 1.8 cm 의 cystic echo 가 관찰됨 .
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Problem List #1. DM, poorly controlled #2. Mild overweight #3. Hypertension #4. HFS s/p MVD #5. Heavy Smoker #6. Alcoholics
#7. Fatty liver #8. A 1.8 cm cystic echo in the left kidney.
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Assessment – 2nd
I. #1, #3, #5, #6 R/O DM Neuropathy (mild 하게 존재 ) R/O DM Nephropathy (Cr 등 정상 ) R/O DM Retinopathy (Fundoscopy 정상 ) R/O Peripheral artery Disease
II. #6, #7 R/O Fatty Liver
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Therapeutic Plan Blood Glucose Level Control
Continuous HTN Control
금연 , 음주 교육 ( 지방간 관련 )
Pregabalin (for DM neu-ropathy)
Metformin
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Treatment of DM – Goal Blood Pressure
SBP < 130, DBP < 80 mmHg ACEi, ARB: drug of choice
Lipid management LDL < 100, HDL > 50, TG < 150 mg/dL Overt CVD: LDL < 70 Statin
Antiplatelet agents
Inda-pamide
NifedipineLosartan
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Treatment of Fatty liver 원인 제거 및 생활습관 개선이 중요
체중감량 , 지방섭취 제한 , 운동 지질 강하 목적으로 Fenifibrate 사용