dyspnea, muscle clump,...

Case conference

TAKUGA HINOSHITA 2nd resident ONMC

38 y/o female, Japanese CC: Dyspnea, Muscle clump, Numbness

HPI Since 1 week PTA, she’s been complaining of fever around 38℃, chills, cold sweat and nocturnal dyspnea.

2 ～ 3 days PTA, she started to have numbness and Pngling at both of her lower extremiPes, which gradually spread to her whole body.

on admission day, because weird sensaPon, muscle clump, SOB, and orthopnea were begun during sleeping, she was admiSed to ER by ambulance. She also complained of slight hair loss, rhinorrhea, hot flushing, palpitaPon, and nausea. There were no headache and diarrhea.

PMH/FHx/SHx # HTN: since high school, 180/130 mmHg # PyronephriPs: 14 years ago # Pneumonia: 8 years ago # Asthma: 4 years ago # Hypocalcemia: 3 years ago, hospitalized Heart/Liver/Diabetes/Thyroid/Parathyroid φ Hx of surgical operaPon φ MedicaPon φ, NKDA Para 0000, 1st period 14 y/o, 2 – 3/year, quite heavy Father: HTN, anemia Aunt: asthma Smoke: 1PPD×20years, currently 1～2 pieces/d ETOH: cocktail 500ml×4～5/d = 2000～2500ml/d (120～150g) Diet: light, unbalanced, water 2L/d instead Married, Caring for her parents everyday No helper, Private Pme restricted

System review General Dermatological Head Eyes Ears Nose Mouth & Throat Neck Cardiovascular Respiratory Breast GastrointesPnal Renal & Urological Endocrine Musculoskeletal & Ext. ReproducPve Neurological Behavioral & Psychiatric

PEx BP 180/100mmHg, HR 116/min, RR 36/min, SpO2(RA) 96%, BT 37.2℃ H 149 cm, W 47kg, BMI 21.2 GCS 15pts, alert, General slightly sick HEENT: PERRLA, pale conjuncPva (＋), icteric(－), fundus micro hemorrhage (＋),

rhinorrhea(＋), wet mouth, tongue not swollen/shrunk, lip cyanosis(－), CLN/SCLN(－), JVD(＋), goiter(－), pharynx not reddish, tonsil not swollen

Heart: regular, S1(↑)S2(↑)S3(＋)S4(＋) Lung: wheeze(－), crackle(＋)@right side chest Abd: son, flat, tenderness(－), mass(－), hepatosplenomegaly(－) Back: CVA tenderness(－) Ext: warm, edema(－), asterixis(－), clubbing(－), Trousseau sign(＋) Skin: rash(－), taSoo(＋) MMT: b/l 5/5 DTR: systemically hyperreflex (3＋), Babinski(－) CNS: n.p. Sensory/VibraPon: n.p.

Labo data CBC : WBC 6,700/μL Hb 6.9g/dl, Hct 22.6%, MCV 68fL, Ret 12‰ PLT 229,000/uL

Chemi : Na 144mEq/L , K 3.1mEq/L, Cl 106mEq/L, Ca 6.4mg/dl, Mg 1.0mg/dl, IP 2.7mg/dl BUN 7mg/dl, Cre 0.5 mg/dl, GOT 78 IU/L, GPT 26 IU/L, ALP 293 IU/L LDH 349 IU/L, T-‐Bil 0.8mg/dl, BS 106mg/dl, CPK 176 IU/L, CK-‐MB 7 IU/L TSH 1.755 μU/mL, vit.B12 173pg/mL, TP 6.5 g/dL, Alb 3.6 g/dL Fe 41 μg/dL, TIBC 449 μg/dL, FerriPn <3 ng/mL

ABG (ambient air) : pH 7.503, pCO2 34.1 mmHg, pO2 75.9 mmHg, HCO3-‐ 26.5 mmol/L

UA : U Osm 1.013, pH 7.5, protein (－), occult blood (－) U-‐Na 224 mEq/L, U-‐K 9.3 mEq/L, U-‐Cl 173 mEq/L, U-‐Ca 6.8 mg/dL

Labo data

Na 144 mEq/L CPK 176 IU/L Fe 41 μg/dL pH 7.503

K 3.1 mEq/L CK-‐MB 7 IU/L TIBC 449 μg/dL pCO2 34.1 mmHg

Cl 106 mEq/L WBC 6,700 /μL UIBC 408 μg/dL pO2 75.9 mmHg

Ca 6.4 mg/dl RBC 3,330,000 /μL Ret 12  　 ‰ K+ 2.7 mmol/L

Mg 1.0 mg/dl Hb 6.9 g/dl FerriPn <3 ng/mL Ca++ 0.96 mmol/L

IP 2.7 mg/dl Ht 22.6 % A/G 1.2 HCO3-‐ 26.5 mmol/L

BUN 7 mg/dl MCV 68 fL BNP 544.3 pg/mL U Osm 1.013

Cre 0.5 mg/dl MCH 20.8 pg int-‐PTH 54 pg/mL U pH 7.5

GOT 78 IU/L MCHC 30.8 % vit.D 54.7 pg/mL U-‐Na 224 mEq/L

GPT 26 IU/L PLT 229,000 /uL U-‐K 9.3 mEq/L

ALP 293 IU/L Free T-‐3 2.83 pg/mL U-‐Cl 173 mEq/L

LDH 349 IU/L Free T-‐4 0.71 ng/mL Vit.B1 42 ng/mL U-‐Ca 6.8 mg/dL

T-‐Bil 0.8 mg/dl TP 6.5 g/dL Vit.B12 173 pg/mL U-‐IP 50.5 mg/dL

BS 106 mg/dl Alb 3.6 g/dL Folate 8.5 ng/mL U-‐Mg 13.0 mg/dL

ohters

Echocardiogram : diffuse hypokainesis of the LV wall, diffuse wall thickning, no valvular Dx

CT : almost normal findings

Problem list Dyspnea Night sweat Muscle clump Numbness Vomit URI symptom(＋) HTN SpO2↓ CHF Anemia

Respiratory acidosis Metabolic alkalosis K/Ca/Mg↓ LFTs↑ BNP↑ Alcohol smoke Dismennorhea Short stature?

# HF # Anemia # HTN # Lytes↓ # Alcoholism # Myoma/ dysmenorrhea # Muscle clump/ Numbness

Heart Failure

d/t… HTN, Anemia, Alcohol, NaCl intake↑? Len Ventricular hypokinesis 1st:cardiomyopathy(HCM,DCM)? 2nd:ETOH,Collagen,Amyloidosis, BeriBeri,IHD? ⇒vit B1 normal, ANA etc are negaPve

Anemia Fe↓, ferriPn↓ ⇒IDA s/o d/t myoma vit.B12↓ →vit.B12 defeciency, macrocytosis is combined? d/t alcoholism ? Atrophic gastriPs? Intrinsic factor deficiency? ⇒gastroscope showed the normal findings. likely to have… Chronic GI tract bleeding, hemorrhoid, menstraPon defect malnutriPon, malabsorpPon syndrome, others

HTN

1st: familial, environmental, NaCl++, 2nd: renovascular, Aldsteronism?, Pheochromocytoma?

Abd.echo & CT → r/o adrenal tumor and renovascular stenosis ⇒ negaPve findings Renin acPbity / aldosteron, catecholamines ⇒nomal range

Electrolytes

Mg↓→ Ca/K↓ d/t…alcoholism vomit, diurePc, purge, vit.D↓, Aldsteronism, parathyroid hormone↓

Gitelman synd?, Barter synd?, Liddle synd?

⇒ PTH normal, vit D normal Renin/ald normal

Muscle clump/ Numbness

Muscle clump : Ca↓, Neuro-‐muscular Dx(vitB1↓, vitB12↓, Alcohol↑）, K↓, others

Numbness : Ca↓, Neuro-‐muscular Dx(vitB1↓, vitB12↓,folate↓ Alcohol↑）, K↓, others

⇒vit.B1 and folate is normal

CHF

ETOH

Lyte • Mg↓ • K↓

• Ca↓

Muscle clump and numbness

Malnutri>on

• B12↓

HTN

• What is cause?

Anemia d/t IDA myoma

Conclusion ??

# Hypertensive heart ? # Electrolytes deficit d/t alcohol # Hypertension …There is no apparent 2nd HTN, hormonal nor renovascular.

# vit.B12↓

dyspnea, muscle clump,...

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