1. MGR Division of pulmonary and critical care medicine Department of Internal Medicine, Kyung Hee University College of Medicine R1 김은영

2. Chief complaint Fatigue recent o/s)1 month ago remote o/s)5 years ago Present illness 97 년부터 고혈압 약 복용하고 있으며 5 년 전부터 자주 피로감 느껴 외부병원 건강검진 시행, CXR 에서 Multiple pulmonary nodule 발견, Bronchoscopy, TBLB 시행 받았으나 특이 소견 없었다 하며 이후 별 문 제 없이 지내다 내원 한달 전부터 피로감 심해져 과거 폐질환력 고려 하여 호흡기 내과 외래 방문, VATS Biopsy 권유 받고 입원 10987617 한 O 숙 F/41 Adm.via OPD.07-04-03

3. Past medical history DM/HTN/Tb/Hepatitis(-/+/-/-) :ARB 복용해옴 Multiple pulmonary nodule (+): 진단받지 못함. OP Hx(+) Hysterectomy d/t uterine leiomyoma 97’ Family history : Family history : None Personal history Smoking (-) Alcohol (-)

4. Review of System General fatigue (+) Wt loss(+) 2~3kg/6months febrile sensation (-) chilling (-) myalgia (-) night sweat(-) Skin rash (-) itching (-) pigmentation (-) Head & Neck headache(-) diplopia(-) tinnitus(-) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) hemoptysis(-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5. Review of System Gastrointestinal swallowing (-) jaundice (-) abdominal pain (-) A/N/V/D/C (+/-/-/-/-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) oliuria (-) Musculoskeletal pain (-) weakness (-) cramp (-) Neurologic syncope (-) seizure (-) dizziness (-)

6. Physical Examination Vital sign : 110/70 – 78 회 /min – 20 회 /min - 36°c SPO2 : 99% (RA) General alert mentality chronic ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement cervical LN enlargement (-) Eye & ENT isocoric pupil PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

7. Physical Examination Thorax Bilateral symmetric expansion Clear breathing sound without R or W Regular heart beat without murmur Abdomen Soft & flat normoactive bowel sound tenderness (-) rebound tenderness (-) rigidity (-) muscle guarding (-) no palpable mass no abdominal bruit Back & Extremity CVA tenderness (-/-) pretibial pitting edema (-/-)

8. Initial lab finding CBC/DC 7290/mm² -15.9 g/dl – 44.3 %- 262K (seg : 53.8%) Chemistry TB 0.88 mg/dL AST/ALT 30/18 U/L ALP/rGT 72/12 U/L Protein/alb 7.5/4.7 g/dL LD/CK 406/49 U/L BUN/Cr 11/0.7 mg/dL Na/K/Cl 134/3.7/106mmol/L ABGA 7.419 –35.2 – 76.9 – 22.2 –95.7 UA RBC 0-1/HPF WBC 0-1/HPF Bilirubin (-) Urobilinogen (-) Ketone (-) SG 1.025 Protein (-)

9. HR : 75 회 /min EKG

11. Problem list 1. multiple pulmonary nodule 2. fatigue 3. Wt loss 4. well controlled HTN 5. s/p Hysterectomy

12. Initial assesment 1, 2, 3 Metastatic solid organ malignancy R/O Benign nodule R/O Infectious granuloms (fungal infection,Tb) R/O Infectious granuloms (fungal infection,Tb) R/O Sarcoidosis R/O Sarcoidosis R/O Pneumoconioses R/O Pneumoconioses R/O Pulmonary AVMs R/O Pulmonary AVMs4.HTN 5.S/P Hysterectomy

13. Plan 1.2.3 Get old CXR, Chest CT Sputum cytology,AFB stain,culture Tumor marker Abdomen and pelvic CT 4. Antihypertensive med. 지속

14. OLD CXR 03-10-29

16. Lab data Sputum AFB stain negative Sputum AFB stain negative Urine legionella,streptococci negative Urine legionella,streptococci negative Cold agglutitin,mycoplasma WNR Cold agglutitin,mycoplasma WNR Direct smear not found Direct smear not found Sputum cytology WNR Sputum cytology WNR CA 19-9 7.77U/ml CA 19-9 7.77U/ml AFP 1.38ng/ml AFP 1.38ng/ml CEA 0.598ng/ml CEA 0.598ng/ml CA125 14.5U/ml CA125 14.5U/ml

17. Accessment Benign metastasizing leiomyoma R/O Metastatic solid organ malignancy Plan VATS Biopsy

18. VATS biopsy Op date 07-04-06 Op name Wedge resectional bx by VATS Frozen biopsy from LLL >> smooth muscle tumor 07-04-12 Pathologic confirm Dx Benign metastasizing leiomyoma IHC finding ER(+, 40%), PR(+, 50%), C-kit(-)

21. Benign metastasizing leiomyoma Therapeutic plan Hormonal Tx Final Dx