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건강 검진에서 발견된 위선종 73/M 소화기 내과 R 3 김혁 / Prof. 장영운 2011.10.06 MGR.

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Presentation on theme: "건강 검진에서 발견된 위선종 73/M 소화기 내과 R 3 김혁 / Prof. 장영운 2011.10.06 MGR."— Presentation transcript:

1 건강 검진에서 발견된 위선종 73/M 소화기 내과 R 3 김혁 / Prof. 장영운 2011.10.06 MGR

2 12172865 서 O 호 (M/73) Adm. : 11. 02. 10 Chief complaint – 건강검진에서 발견된 위선종 Present illness –M/73, 평소 특이 병력 없던 자로 외부 병원에서 시행한 건강 검진 위 내 시경에서 이상소견 보여 조직검사 시행함. – 조직검사 결과 gastric adenoma, low grade dysplasia 진단받고 적극적 인 치료 위하여 입원함. History

3 Past Medical History DM/HTN/TBc/Hepatitis(-/-/-/-) Medication Hx (+) –H. pylori eradication Op Hx(-)

4 Personal History Alcohol (+) – 소주 1 병, 7 회 /wk. Smoking (+) – 과거 흡연 : 40 갑년 Family History None

5 Review of System 1. General Generalized weakness(-) Fever(-) Chill(-) Myalgia(-)Weight change(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(-) Dizziness(-) 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(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(-) swelling(-) Tenderness(-) Backpain(-) Myalgia(-) Numbenss(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Review of System

7 Physical Examination Height : 176.7 cm Weight : 77.6 kg BMI : 24.9 kg/m 2 Vital Sign : 120/80 mmHg - 56/min - 20/min – 36.7 ℃ 1. General appearance Alert consciousness NOt 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 4. Chest Symmetric chest expansion Clear breating sound without rale/wheezing Regular Heart Beat without murmur 5. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-), Hepatomegaly(-) 6. Back&extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-)

9 Initial Lab Finding 1.CBC/DC 6750 / ㎕ – 14.2 g/ ㎗ – 39.8% - 196,000 / ㎕ aPTT 31.1 sec PT INR 0.90 2.Chemistry TB / DB0.56/ 0.17 mg/ ㎗ BUN/Cr18 / 0.8 mg/dL Protein/Albumin7.5 / 4.2 g/ ㎗ Na/K/Cl 142 / 4.1 / 103 mEq/L AST/ALT28/ 24 U/L Ca/P/Mg 8.4 / 3.0 / 2.3 mg/dL ALP/rGT63 / 20 U/L Uric acid7.7 mg/dL CRP <0.3 mg/dL 3.UA RBC 0~1 /HPF WBC 0~1 /HPF Blood - Protein - Glucose - Bilirubin -

10 Initial Chest PA

11 Initial ECG

12 #1. gastric adenoma, low grade dysplasia #2. pleural thickening and calcification #3. sinus bradycardia & LVH Initial Problem Lists

13 #1. gastric adenoma, low grade dysplasia 1) Diagnostic evaluation - EGD & CLO test - 외부 abd CT 에 대한 재검토 2) Treatment - ESD or EMR - if CLO(+)  H. pylroi eradication Initial Assessment and Plan

14 #2. r/o pulmonary Ds 1) Diagnostic evaluation - 외부 chest CT 재검토 - 필요시 TB or cancer evaluation 2) Treatment - 검사 결과에 따라 결정 Initial Assessment and Plan

15 #3. sinus bradycardia & r/o HTN 1) Diagnostic evaluation - PR monitoring & syncope or Dz 와 같은 증상 유무 재확인 - BP monitoring 2) Treatment - 필요시 medication 추가 Initial Assessment and Plan

16 Clinical Course

17 Clinical Course – Before admission 1/15 건강검진 ( 외부병원 ) 조직검사 결과 : gastric adenoma, low grade dysplasia

18 Clinical Course ‘11 1/15 2/10 Adm & ESD

19 Clinical Course ‘11 1/15 2/11 f/u EGD 2/10 Adm & ESD

20 Clinical Course ‘11 1/15 2/11 f/u EGD 2/12 discgarge 2/10 Adm & ESD 외부병원 조직검사 결과 : gastric adenoma, low grade dysplasia

21 Tissue

22 Clinical Course ‘11 1/15 2/11 f/u EGD 2/12 discgarge 2/10 Adm & ESD 9/29 f/u EGD 3/23 f/u EGD

23 #1. Early gastric cancer-IIc Final Diagnosis


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