M G R 호흡기내과 R1 구자원 / Prof. 박명재

조 O 숙 F/61 Chief Complaint Chief Complaint Dry Cough o/s) 1 month ago Dry Cough o/s) 1 month ago Present Illness Present Illness HTN 외에 특이병력 없는자로 1 달 전부터 마른 기침 발생하여 동네의원에서 처방받은 약 복용하였으나 증 상 호전 없고 내원 1 주 전부터는 dyspnea 동반되어 2 차 병원 방문, chest X-ray 및 chest CT 시행 후 lung cancer 의심되어 further evaluation 위해 본원 내원 HTN 외에 특이병력 없는자로 1 달 전부터 마른 기침 발생하여 동네의원에서 처방받은 약 복용하였으나 증 상 호전 없고 내원 1 주 전부터는 dyspnea 동반되어 2 차 병원 방문, chest X-ray 및 chest CT 시행 후 lung cancer 의심되어 further evaluation 위해 본원 내원

Past Medical History Past Medical History DM/HTN/Tb/Hepatitis (-/+/-/-) DM/HTN/Tb/Hepatitis (-/+/-/-) HTN : 10 년전 진단, atenolol 25mg qd Op Hx (+) : C-sec (35 년전 ) Op Hx (+) : C-sec (35 년전 ) Family History Family History Unremarkable Unremarkable Personal History Personal History Smoking (-) Smoking (-) Alcohol (-) Alcohol (-) Occupation : 목사 Occupation : 목사

Review of System General fatigue (-) febrile sense (-) weight change (-) General fatigue (-) febrile sense (-) weight change (-) Skin rash (-) itching (-) pigmentation (-) Skin rash (-) itching (-) pigmentation (-) Head & Neck headache (-) sore throat (-) neck stiffness (-) Head & Neck headache (-) sore throat (-) neck stiffness (-) Eye & ENT visual disturbance (-) tinnitus (-) rhinorrhea(-) Eye & ENT visual disturbance (-) tinnitus (-) rhinorrhea(-) Respiratory dyspnea (+) cough (+) sputum (-) Respiratory dyspnea (+) cough (+) sputum (-) Cardiac chest wall pain (+) palpitation (-) DOE (+) Cardiac chest wall pain (+) palpitation (-) DOE (+) Cough, Breathing 시 악화 NYHA IIDry coungh

Review of System Gastrointestinal A/N/V/D/C (+/-/-/-/-) abd. pain (-) Gastrointestinal A/N/V/D/C (+/-/-/-/-) abd. pain (-) melena (-) hematemesis (-) melena (-) hematemesis (-) Urinary dysuria (-) frequency (-) flank pain (-) Urinary dysuria (-) frequency (-) flank pain (-) Musculoskeletal LBP (-) pph. Edema (-) Musculoskeletal LBP (-) pph. Edema (-) Neurologic dizziness (-) numbness (-) weakness (-) Neurologic dizziness (-) numbness (-) weakness (-)

Physical Examination Vital sign : 140/90 mmHg – 68 회 /min – 20 회 /min – 36.0°c Vital sign : 140/90 mmHg – 68 회 /min – 20 회 /min – 36.0°c Ht cm Wt Kg BMI 24.4 Kg/m² Ht cm Wt Kg BMI 24.4 Kg/m² General General Alert consciousness Alert consciousness Chronic ill looking appearance Chronic ill looking appearance Skin Skin No rash No rash No pigmentation No pigmentation Head & Neck Head & Neck No cervical LN enlargement No cervical LN enlargement No neck vein engorgement No neck vein engorgement No palpable neck mass No palpable neck mass Eye & ENT Eye & ENT Isocoric pupil with PLR (++/++) Isocoric pupil with PLR (++/++) Clear sclera, pinkish conjunctiva Clear sclera, pinkish conjunctiva

Physical Examination Thorax Thorax Decreased breathing sound with rale on BLLF (Rt>Lt) Decreased breathing sound with rale on BLLF (Rt>Lt) Regular heart beat without murmur Regular heart beat without murmur Abdomen Abdomen Soft and mild obese abdomen Soft and mild obese abdomen Normoactive bowel sound Normoactive bowel sound Abd. tenderness / rebound tenderness (-/-) Abd. tenderness / rebound tenderness (-/-) No hepatomegaly or splenomegaly No hepatomegaly or splenomegaly Back & Extremities Back & Extremities CVA tenderness (-/-) CVA tenderness (-/-) Pretibial pitting edema (-/-) Pretibial pitting edema (-/-) No joint deformity or swelling No joint deformity or swelling

Initial Lab Findings CBC/DC 9,150/mm² g/dl – 41.9% - 314K (seg. 76.7%) 9,150/mm² g/dl – 41.9% - 314K (seg. 76.7%) PT (INR) 0.95 aPTT 40.4 PT (INR) 0.95 aPTT 40.4Chemistry TB/DB 0.95/0.14 mg/dL AST/ALT 40/16 IU/L TB/DB 0.95/0.14 mg/dL AST/ALT 40/16 IU/L ALP/GGT 65/14 IU/L Prot/Alb 6.8/3.9 g/dL ALP/GGT 65/14 IU/L Prot/Alb 6.8/3.9 g/dL BUN/Cr 8/0.6 mg/dL Na/K/Cl 138/4.3/101 mmol/L BUN/Cr 8/0.6 mg/dL Na/K/Cl 138/4.3/101 mmol/L CRP 6.7 Ca/P/Mg 8.4/3.7/2.2 mg/dL CRP 6.7 Ca/P/Mg 8.4/3.7/2.2 mg/dL LD/CK 660/388 U/L Glucose 117 mg/dL LD/CK 660/388 U/L Glucose 117 mg/dL Tumor marker CEA CA SCC 0.4 CEA CA SCC 0.4 CA CA CA CA U/A RBC 0~1/HPF WBC 0~1/HPF Proteinuria (-) RBC 0~1/HPF WBC 0~1/HPF Proteinuria (-)

EKG HR :75 회 /min

Chest PA

Chest CT

Problem list Problem list & Initial assessment Rt. Pleural effusion Dry Cough Dyspnea Pleuritic pain #1.Parapneumonic effusion TB pleurisy TB pleurisy Mesothelioma Mesothelioma Effusion secondary to Malignancy Effusion secondary to Malignancy #2 HTN, known Cirrhosis Nephrosis CHF Rheumatoid pleuritis

Diagnositic & Therapeutic Plan Diagnostic Plan Parapneumonic effusion Parapneumonic effusion Pleural fluid (Gram stain, culture, Cell count) Pleural fluid (Gram stain, culture, Cell count) Sputum (Gram stain, Culture) Sputum (Gram stain, Culture) Blood Culture, Mycoplasma Ab, CBC/DC, CRP Blood Culture, Mycoplasma Ab, CBC/DC, CRP Urine (pneumococcal Ag, Legionella Ag) Urine (pneumococcal Ag, Legionella Ag) TB pleurisy TB pleurisy Pleural fluid (AFB, TB culture, TB PCR, ADA) Pleural fluid (AFB, TB culture, TB PCR, ADA) Sputum (AFB, TB culture, TB PCR) Sputum (AFB, TB culture, TB PCR) Mesothelioma, Effusion secondary to Malignancy Mesothelioma, Effusion secondary to Malignancy Pleural fluid cytology Pleural fluid cytology Pleural biopsy Pleural biopsy Tumor marker Tumor marker Abd. CT Abd. CT Therapeutic Plan Pleural fluid drainage Pleural fluid drainage Conservative Manage Conservative Manage

Pleural fluid analysis CBC/DC CBC/DC RBC 7200 WBC 390 (Lymph 77%) RBC 7200 WBC 390 (Lymph 77%) Chemistry Chemistry LD 1679 Protein 4200 Albumin 2.5 pH Glucose 4 ADA 32.8 AFB : negative Gram stain : Not found Culture : No growth Pathology Pathology No malignant cells

VATS Pleural biopsy Op finding : Multiple pleural(visceral/parietal) seeding 관찰됨 Pleural fluid : Sero-sanguious Pleural adhesion (+)

Pathologic Finding x40x400

Imunohistologic finding CaletininD2-40 TTF-1 Immunohistochemical finding: CK7 (+), CK20 (-), CK5 (-), Caletinin (+, focal),D2-40 (+) P63 (-), CEA (-), CD15 (-), TTF-1 (-)

Pelvic CT

Final diagnosis 1. Malignant Pleural Mesothelioma

Clinical course Transfer to SNU Transfer to SNU Chemo Tx. Chemo Tx. Surgical resction Surgical resction