1. 갑작스런 호흡부전을 주소로 내원한 75 세 여자환자 2009.10.01 Department of pulmonolgy R1. lee jung hoon/ prof. park myung jea Case Conference

2. Case 1 Case Conference

3. 2009-02-08 10845831 윤 O 연 (F/75) C.C) Dyspnea o/s) 4 days ago P.I) 75 세 여자환자, 87’ MVR c mechanical valve d/t MR 시 행 후 IC (prof. 김권삼 ) OPD f/u 하던 자로, 내원 4 일전 부터 발생한 dyspnea 있어 local 방문하였으나 증세 더욱 악화되어 ER 경유 adm.

4. History PMHx) DM/HTN/Tbc/hepatitis (-/+/-/-) OPHx) MVR with mechanical valve d/t MR (87’ 고대 구로 병원 ) : warfarin 3mg qd 복용중. Cataract (+) : 15 년전 op. PHx) Smoking (-) Alcohol (-) FHx) None

5. Review of system 1.General Generalized weakness (+) Fever(-) Chill (-) Insomnia (-) Weight change (-) Poor oral intake (+) 2.Skin Rash (-) Pigmentation (-) Itching (-) Urticaria (-) 3. HEENT Headache (-) Visual disturbance (-) Nasal obstruction (-) PND (-) Sore throat (-) Neck mass(-) 4. Respiratory Cough (+) Sputum (+) : yellowish Rhinorrhea (-) Dyspnea (+) : MRC grade V Hemoptysis (+) : 4 일전 blood-tinged sputum

6. Review of system 5. Cardiac Chest discomfort (-) Dyspnea of exertion (+) Orthpnea (-) Palpitation (-) 6. GI A/N/V/D/C (+/+/+/-/-) : 입원 후 1 회 vomitting Abdominal pain (-) Melena (-) Hematochezia (-) 7. Renal & urinary Dysuria (-) Hematuria (-) Urgency (-) Freqency (-) Residual urine sense (-) Incontinence(-) 8. Musculoskeletal Myalgia (-) Back pain (-) Sprains(-) Fracture(-) Swelling (-) 9. Nervous Syncope(-) Seizure (-) Dizziness (-) Tremor(-)

7. Physical examination V/S 140/80mmHg - 82/min - 32/min - 36.0 c SpO2 87% 1. General Alert consciousness Acute ill looking appearance 2. Skin No rash No Pigmentation 3. H & ENT Stridor (+) Neck stiffness (-) Conjuntival injection (-) Diplopia (-/-) Tonsil enlargement (-) Neck vein engorgement (-) LN enlargement (-) Carotid bruit (-)

8. Physical examination 5. Chest Symmetric chest expansion Coarse breath sound with wheezing on BLF Irregular heart beat without murmur 6. Abdomen Mild soft & distended abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness(-) Muscle guarding (-) 7. Back/Ext CVA Td (-/-) Pretibial pitting edema (-/-) 8. Neurologic Sensory Motor 100 Ⅴ Ⅴ Ⅴ Ⅴ

9. Initial lab finding 1. CBC/DC 4370/mm 3 – 12.1 g/dL – 34.1 % - 214000 /mm 3 (Seg. 70.7%) PT 27.7 (INR 2.53) aPTT 68.5 2. Chemistry Prot/Alb 7.9/4.5 (g/dL) TB/DB 1.1/0.45 (mg/dL) AST/ALT 28/12 (mg/dL) ALP/rGT 126/72 (IU/L) BUN/Cr 12/0.5 (mg/dL) Na/K/Cl 127/3.8/78 (mEq/L) Ca/P/Mg 8.7/2.8/1.7 (mg/dL) CRP 0.6 (mg/dL) CK/CK-MB 94/2.5 (IU/L) TnI 0.02 (ng/mL) Glucose 142 (mg/dL) LD 94 (U/L) BNP 325 (pg/mL) 3. U/A RBC 0~1/HPF WBC 0~1/HPF 4. ABGA (room air) pH 7.44 pCO2 42.6 pO2 55.1 HCO3 28.5 SO2 89.8%

10. Chest X-ray 08.05.0709.02.09

11. Chest X-ray (09.02.09)

12. EKG 05.08.15

13. 09.02.09

14. Problem list #1. Airway obstruction disease r/o asthma #2. MR s/p MVR state #3. CHF, Atrial fibrillation #4. Hypertension #5. Elevated LFT

15. Initial accessment & plan #1. r/o airway obstruction disease  bronchodilator PFT chest CT, bronchoscopy #2. CHF s/p MVR c mechanical valve d/t MR  echocardiopraphy #3. Atrial fibrillation #4. Hypertension  기존 po medi 유지 #5. Elevated LFT  AP sono

16. HD#1.Echocardiography (02.08)

21. HD#3.bronchoscopy(02.10)

22. Clinical course Tracheobronchomalacia ① stent insertion ② surgical repair NIPPV 사용하여 CPAP mode 적용 !! 7 일간의 치료 후 정상호흡음, dyspnea 개선

23. HD#9. bronchoscopy(2.16)

24. HD#10. PFT (2.17)

25. Final diagnosis #1. Tracheobronchomalacia #2. MR s/p MVR state #3. CHF, AF #4. Hypertension

26. Case 2 Case Conference

27. 2009-07-09 10921860 홍 O 식 (M/68) C.C) Dyspnea o/s) remote : 3 days ago recent : 내원 오전 P.I) 68 세 남자환자, HTN, sigmoid colon cancer s/p colonostomy & lower anterior resection, cerebral infarction 과거력있는 자로 내원 3 일전 식사시 자주 사래 들리는 양상 있었고 cough, sputum, dyspnea 발생하여 local 방문하여 asthma 의심하에 medication 중 내원 당일 오전 식사량 줄고, dyspnea 호소하며 화장실에 쓰러져 있는 모습 보고 보호자 발견하여 ER 방문하여 drowsy mentality, saturation 60% check 되어 intubation 시행후 ICU 로 입원함.

28. History PMHx) DM/HTN/Tbc/hepatitis (-/+/-/-) Cb. Infarction (+) : 06’ 11 월 Rt. side weakness 발생 ( 본원 FM) Sigmoid colon ancer T-loop colonostomy (01’ 1 월 31 일 ) Ant. Resection (01’ 2 월 16 일 ) Colostomy Takedown (01’ 6 월 26 일 ) PHx) Smoking (-) : ex-smoker 40pack years, 8 년전 금연 Alcohol (-)

29. Review of system 1.General Generalized weakness (-) Fever(-) Chill (-) Insomnia (-) Weight change (-) Poor oral intake (+) 2.Skin Rash (-) Pigmentation (-) Itching (-) Urticaria (-) 3. HEENT Headache (-) Visual disturbance (-) Nasal obstruction (-) PND (-) Foreign body sensation (+) 4. Respiratory Cough (+) Sputum (+) Rhinorrhea (-) Dyspnea (+) 점차 악화되는 양상 목에 걸리는 느낌 컹컹 거리는 소리

30. Review of system 5. Cardiac Chest discomfort (-) Palpitation (-) Orthpnea (-) 6. GI A/N/V/D/C (-/-/-/-/-) Abdominal pain (-) Melena (-) Hematochezia (-) 7. Renal & urinary Dysuria (-) Hematuria (-) Urgency (-) Freqency (-) Residual urine sense (-) Incontinence(-) 8. Musculoskeletal Myalgia (-) Back pain (-) Rt. Side weakness (+) Sprains(-) Fracture(-) Swelling (-) 9. Nervous Syncope(+) Seizure (-) Dizziness (+) Tremor(-)

31. Physical examination V/S 150/100mmHg - 157/min - 30/min - 36.2 c SpO2 58% 1. General Alert consciousness Acute ill looking appearance 2. Skin No rash No Pigmentation 3. H & ENT Tonsil enlargement (-) Neck vein engorgement (-) LN enlargement (-) Carotid bruit (-) Neck stiffness (-) Neck mass (-)

32. Physical examination 5. Chest Symmetric chest expansion Stridor & wheezing on both lung field Tachycardia without murmur 6. Abdomen Mild soft & distended abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness(-) Muscle guarding (-) 7. Back/Ext CVA Td (-/-) Pretibial pitting edema (-/-)

33. Initial lab finding 1. CBC/DC 18340/mm 3 – 15.3 g/dL – 48.4 % - 289000 /mm 3 (Seg. 45.6%) PT 13.6 (INR 1.03) aPTT 36.1 2. Chemistry Prot/Alb 7.2/4.2 (g/dL) TB/DB 0.7/0.25 (mg/dL) AST/ALT 25/15 (mg/dL) ALP/rGT 79/17 (IU/L) BUN/Cr 20/1.3 (mg/dL) Na/K/Cl 141/3.2/95 (mEq/L) Ca/P/Mg 8.7/2.8/1.7 (mg/dL) CRP 3.0 (mg/dL) CK/CK-MB 118/2.2 (IU/L) TnI 0.02 (ng/mL) Glucose 168 (mg/dL) LD 383 (U/L) 3. ABGA (room air) pH 7.067 pCO2 79.8 pO2 39.8 HCO3 22.4 SO2 50.4% 4. U/A RBC 0~1/HPF WBC 2~4/HPF

34. Chest X-ray (09.07.09) 06.11.23 09.07.09

35. Problem list #1. Respiratory arrest d/t r/o asphyxia r/o COPD acute exacerbation r/o upper airway obstruction #2. r/o aspiration pneumonia #3. old cerebral infarction #4. colon cancer s/p colostomy & ant. resection state

36. Initial accessment & plan #1. Respiratory arrest #2. r/o aspiration pneumonia  ER 에서 intubation 시행후 의식 회복된 상태, T-piece 0.5 유지 culture & antibiotics start (levofloxacin + clindamycin) CXR, ABGA f/u chest CT #3. Old cerebral infarction  brain CT #4. Colostomy & ant. Resection state d/t colon cancer  observation

37. HD#1 (7/10) #1. S) dyspnea(-) O) alert mentality RR 12 회 Am 9:00 T-piece FiO 2 0.24 4L SPO 2 100% 유지 Wheezing(-) stridor(-) AM 10:30 extubation 시행  post-extubation stridor 와 함께 dyspnea 발생  reserve mask SPO 2 40% 로 감소  re-intubation 시행 A) upper respiratory tract obstruction P) Tracheostomy (7/11) bronchoscopy chest CT, NECK CT

38. HD#5 (7/13) : bronchoscopy

39. HD#6 Chest CT (7/14)

47. Diagnosis #1. Respiratory arrest d/t vocal cord mass  ENT consult 후 op 계획 #2. r/o aspiration pneumonia  기존 antibiotic (levofloxacin+clindamycin) 유지 #3. old cerebral infarction #4. colostomy & ant. resection state d/t colon cancer

48. HD#14. OP (7/21) : ENT OP name : larynx microsurgery of Rt. TVC mass Bx. : laryngeal leiomyosarcoma, Rt.  Re-operation laser cordotomy (7.29) : margin (-)

49. Final diagnosis #1. Respiratory arrest d/t laryngeal leiomyosarcoma #2. old cerebral infarction #3. colon cancer s/p colostomy & ant. Resection state

50. 감사합니다 !!