Case Presentation 2010/ 03/15

Constipation os) 내원 2개월전 Present Illness CASE 1 M/46 12098235 김 O 준 Admssion date : 2010. 2. 24 Chief Complaint Constipation os) 내원 2개월전 Present Illness M/46 특이 병력 없는 자로 1~2 개월 전부터 constipation 있고 3개월간 3~4 kg wt. loss 있어서 local에서 시행한 대장내시경에서 AV 상방 20cm에 protrudent mass 소견 보여서 F/E & Tx 위해서 내원

Past medical history Family history none Personal history Op Hx (-) DM / HTN / Tbc / Hepatitis (-/-/-/-) Op Hx (-) Drug Hx (-) Family history none Personal history Smoking (+) 20packs year Alcohol (+) 주 2회 소주1병

Review of System General fever(-) chill(-) sweat(-) weight loss(-) Skin rash (-) itching (-) Head & Neck headache (-) stiffness (-) Respiratory cough (-) sputum (-) dyspnea (-) Cardiac chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal A/N/V/D/C (-/-/-/-/+) abdominal pain (-) Urinary dysuria (-) frequency (-) urgency (-) Musculoskeletal weakness (-) numbness (-) Nervous syncope (-) seizures (-) dizziness (-) 4 4 4

Physical Examination Vital sign 120/80 mmHg– 72회/min – 20회/min – 36.3°c General alert consciousness not so ill looking app. Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclera pinkish conjunctiva Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and obese abdomen tenderness (-) rebound tenderness (-) no rigidity no guarding

Initial Lab Findings CBC/DC 6050/mm² - 8.9 g/dL – 28.6% -367k (seg 60.8%) PT 13.3 INR 1.09 a PTT 34.2 Chemistry TB/DB 0.28/0.14 mg/dl CRP:<0.3mg/dL ALP/rGT 62/15 IU/L AST/ALT 14/15 IU/L Prot/Alb 6.5/3.9 g/dL BUN/Cr 15/0.8 mg/dL Na/K/Cl 141/4.0/104 mmol/L TIBC 369 ug/dL s-iron 11 ug/dL CA 19-9 2.41 U/mL AFP 2.01 ng/ml CEA 3.03 ng/ml FeUrea 18.42 prerenal type FeNa 0.07

W/U) Abdominal CT, Chest CT (2/25) Colonoscopy ,gastroscopy (2/25) PET CT (3/2)

IMP) Rectal cancer c r/o colon cancer

Clinical course GS T/F 후 Lap. Rt hemicolectomy & LAR

CASE 2 Chief Complaint Rt flank pain os)2010/01/29 Present Illness F/61 12095102 김 O 숙 Admssion date: 2010.02.02 Chief Complaint Rt flank pain os)2010/01/29 Present Illness 상기 61/F 2년 전부터 HTN(보건소) po med 중인 자 2010 년 1월 29일 부터 시작된 Rt. flank pain 으로 local에서 시행한 CT 상 cystic hepatic mass 로 F/E 위해 OPD 경유 Admission

Past medical history Family history none DM / HTN / Tbc / Hepatitis ( - / + / - /-) Drug Hx (-) Op Hx(-) Family history none Personal history Smoking (- ) Alcohol (+) 주 2회 소주 2병

Review of System General : fever(-) chill(-) fatigue(-) weight loss(-) Skin : rash (-) itching (-) Head & Neck : headache (-) stiffness (-) Respiratory : cough (-) sputum (-) dyspnea (-) Cardiac : chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal : A/N/V/D/C (-/-/-/-/-) abdominal pain (-) Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 12 12 12

Physical Examination Vital sign 110/80 mmHg – 64회/min – 20회/min – 36.0°c General alert consciousness acute ill looking app Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclera not pale conjunctiva Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and obese abdomen tenderness (-) rebound tenderness (-) no rigidity no guarding no palpable mass

Initial Lab Findings CBC/DC 10720/mm² - 11.9 g/dl – 37.5% - 525k (seg 60.5%) PT 13.4 INR 1.0 a PTT 42.8 Chemistry TB/DB 0.44/0.20 mg/dL CRP 5.50 mg/dL ALP/rGT 502/1237 IU/L LD/CK 450/34 U/L AST/ALT 151/194 IU/L Amylase/Lipase 79/73 U/L Prot/Alb 7.1/4.2 g/dL BUN/Cr 14/0.5 mg/dL Na/K/Cl 142/4.3/100 mmol/L CA 19-9 11.69 U/mL AFP 1.07 ng/mL CEA 1.67 ng/mL CA 125 13.6 U/mL FeUrea 18.42 prerenal type FeNa 0.07

W/U) Abdominal CT(2/4) ERCP(2/8) EUS(2/8) PET CT (2/11)

IMP) Ampula of Vater cancer c r/o right adrenal gland metastasis r/o functioning adrenal gland mass

Clinical course II 2/25 op 예정으로 GS F/U 하기로하고 Discharge 2/24 GS Admission: PPPD c excision of c adrenalectomy Rt c feeding jejunostomy

Creatinine 24h (U) 0.87g Cortisol(U) 223.1 ㎍/day ACTH(P) 52.2 pg/ml Cortisol(S) 24.4 ug/dL Aldosterone(S) 123.9 pg/ml PRA (P),Renin 2.4 ng/ml/hr VMA(U) 3.6 mg/day Norep(P) 0.27 ng/mL Norep(U) 45.1 ㎍/day Epine(P) 0.04 ng/ml Epine(U) 7.60 ug/day Meta(U) 0.60 mg/day

GS-GI Conference Case 1

12083324 전O영 F/35 C.C) RLQ pain (o/s : 2009.10월 부터) P.I) 특이 병력 없는 자로 2009.10월부터 intermittent RLQ pain 발생해오다, 내원 1달 전부터 PSIS(post.sup. Iliac spine) pain 발생하여 OPD 통해 op 위해 내원함. PMHx) DM/HTN/Hepatitis/Tbc (-/-/-/-) PHx) alcohol(-), smoking(-) OP Hx) 07’ local 의원에서 C/sec 받은 Hx 있음.

ROS) 1. General : fever(-), chill(-), poor oral intake (-) 2 ROS) 1. General : fever(-), chill(-), poor oral intake (-) 2. H&N : headache(-), hearing disturbance (-) 3. Skin : rash(-), itching (-) 4. Chest : dyspnea (-), C/S/R(-/-/-) 5. Cardiac : chest pain(-), palpitation(-) 6. GI : abd.pain(+) : RLQ pain, A/N/V/D/C(-/-/-/-/-), abd.discomfort(+) : dyspepsia hematochezia(-), melena(-) 7. Urinary : dysuria(-), frequency(-) 8. Nervous : syncope(-)

P/Ex) 1. General alert mentality, chronic ill looking appearance 2 P/Ex) 1. General alert mentality, chronic ill looking appearance 2. H&N isocoric pupil c PLR(++/++) NVE (-/-), LNE(-/-) 3. Chest symmetric chest expansion CBS s rale, whizzing RHB s murmur 4. Abdomen soft & flat abdomen normoactive bowel sound Td/RTd (+/-) : RLQ Td(+) 5. Back/Ext CVA Td(-/-) Pitting edema (-/-) 6. Neurology sensory & motor : intact

TB/DB : 0.36/0.18, prot/alb : 8.0/4.4, AST/ALT: 15/10 Initial lab) 2009.12.21 CBC/DC : 5700 – 9.5 – 31.3 – 358K (seg : 65.6%) PT : 14.0 sec (1.06 INR), aPTT : 39.9 sec Chemistry TB/DB : 0.36/0.18, prot/alb : 8.0/4.4, AST/ALT: 15/10 BUN/Cr : 15/0.6, Na/K/Cl : 138/4.5/102, U/A RBC : 0~1, WBC : 0~1 Chest PA no active lung lesion unremarkable

W/U) 2009.11.23 Abd.CT 2010.01.04 Pelvic MRI

Imp) 1. Pelvic teratoma 2. r/o pelvic desmoid tumor Op) 2010. 1 Imp) 1. Pelvic teratoma 2. r/o pelvic desmoid tumor Op) 2010.1.5 Laparoscopic pelvic tumor excision

Case 2

12083888 강O원 M/47 C.C) Bowel habit change (o/s : 약 8개원 전부터) P.I) 특이 병력 없는 자로 8개월 전부터 wt loss(15kg), fatigue 및 상기 Sx 있어, 내원 1주일전 시행한 건강검진에서 DM 진단 받고 insulin 투여 중인 환자로, 내원 당일 시행한 colonoscopy 에서 polyp 및 rectal ca. 진단되어 op 위해 본과로 전과됨. PMHx) DM/HTN/Hepatitis/Tbc (+/-/-/-) : 일주일전 DM 진단 insulin injection 중 PHx) alcohol(+) : social , smoking(+) : 30pack/yrs OP Hx) none

ROS) 1. General : fever(-), chill(-), poor oral intake (-) wt ROS) 1. General : fever(-), chill(-), poor oral intake (-) wt.loss (+) : 15kg, fatigue (+) 2. H&N : headache(-), hearing disturbance (-) 3. Skin : rash(-), itching (-) 4. Chest : dyspnea (-), C/S/R(-/-/-) 5. Cardiac : chest pain(-), palpitation(-) 6. GI : abd.pain(-) , A/N/V/D/C(-/-/-/-/-), abd.discomfort(-) hematochezia(+) : intermittent, melena(-) 7. Urinary : dysuria(-), frequency(-) 8. Nervous : syncope(-)

P/Ex) 1. General alert mentality, chronic ill looking appearance 2 P/Ex) 1. General alert mentality, chronic ill looking appearance 2. H&N isocoric pupil c PLR(++/++) NVE (-/-), LNE(-/-) 3. Chest symmetric chest expansion CBS s rale, whizzing RHB s murmur 4. Abdomen soft & flat abdomen normoactive bowel sound Td/RTd (-/-) 5. Back/Ext CVA Td(-/-) Pitting edema (-/-) 6. Neurology sensory & motor : intact

TB/DB : 0.59/0.16, prot/alb : 7.2/3.9, AST/ALT: 9/7 Initial lab) 2009.12.1 CBC/DC : 7510– 12.2 – 35.7 – 398K (seg : 65.6%) PT : 13.6 sec (1.03INR), aPTT : 38.2 sec Chemistry TB/DB : 0.59/0.16, prot/alb : 7.2/3.9, AST/ALT: 9/7 BUN/Cr : 12/0.5, Na/K/Cl : 136/3.8/102, HbA1c: 13.8 Tumor marker CEA : 18.59, AFP : 2.22 CA19-9 : 106.23 U/A RBC : 0~1, WBC : 2~4 Chest PA r/o bronchial disease on LLLZ

W/U) 2009. 11. 26 Low dose Chset CT(검진) 2009. 12 W/U) 2009.11.26 Low dose Chset CT(검진) 2009.12.1 Gastroscopy Colonoscopy 2009.12.2 Pelvic CT 2009.12.3 Pelvic MRI 2009.12.4 PET-CT

Imp) 1. Rectal ca. 2. DM Op) 2010. 12. 7 Lapa Imp) 1. Rectal ca. 2. DM Op) 2010.12.7 Lapa. APR(Abdominoperineal resection) c permanent end colostomy