1. C.C > No symptom P. I > 특이병력 없던 자, 약 두 달전 목욕탕에서 넘어지면서 우 측 옆구리쪽 통증 지속되어 Abd CT 촬영하였으며 CT 에 서 우연히 pancreatic mass 발견되어 수술적 치료 위해 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/-/-/-) OPHx > (-) 11572686 김 O 자 (F/69)

2. Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

3. Review of Systems 5. Abdomen A/N/V/D/C(-/-/-/-/-) Abd pain(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-)

4. Physical Examination 1.General Alert Mentality Acute ill appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

5. Physical Examination 5. Abdomen Soft & Flat Abdomen Normoactive Bowel Sounds Abd Td/rTd (-/-) Muscle Guarding (-) CVA Td (-/-) Organomegaly (-)

6. Initial Lab. finding CBC 4330 – 14.3 – 43.4 – 310K (seg. 54.0%) Pro/Alb 7.4 /4.5 TB/DB 0.32/0.10 AST/ALT 18/15 ALP / GGT 64/18 BUN/Cr 12/0.6 Na/K/Cl 143/4.5/103

7. Work up Pancreas CT 2011.07.25 S-2011-12591 2011.08.31

8. r/o Pancreas Castleman’s disease Impression

9. Operation Lap. Stomach wedge resection 2011.08.18  PostOp. & Final path. Dx.: Stomach GIST

10. C.C > Anal discharge Adm: 2011.6.9 P. I > 특이병력 없는 자, 2011 년 5 월 23 일 Rectal ca. 로 ISR c loop ileostomy 시행 후 anal discharge 지속되어 management 위해 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/-/-/-) OPHx > (+) 2011. 5.23 ISR c loop ileostomy 30 년 전 cholecystectomy 12197976 최 O 호 (M/64)

11. Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

12. Review of Systems 5. Abdomen A/N/V/D/C(-/-/-/-/-) Abd pain(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Anal discharge(+): pus-like

13. Physical Examination 1.General Alert Mentality Not so-ill looking appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

14. Physical Examination 5. Abdomen Soft & Flat Abdomen Normoactive Bowel Sounds Abd Td/rTd (-/-) Muscle Guarding (-) CVA Td (-/-) Organomegaly (-)

15. Initial Lab. finding CBC 8620 – 11.2 – 27.8 – 514K (seg. 59.9%) Pro/Alb 7.8 /4.2 TB 0.26 AST/ALT 29/35 ALP 162 BUN/Cr 10/0.7 Na/K/Cl 135/4.6/97

16. Work up 외부 abd CT 2011.05.09 Pelvic MRI 2011.05.16 Chest CT 2011.05.17 PET CT 2011.05.17 Abd general CT 2011.05.30 외부 colonoscopy 2011.05.02 EUS 2011.05.13 Sigmoidoscopy 2011.06.28 Sigmoidoscopy 2011.08.09

17. Anastomosis site disruption s/p rectal cancer s/p ISR state Impression

18. Operation Primary closure at anastomosis site 2011.06.10 VAC (Vacuum assisted closure) apply 2011.06.29 / 07.01 / 07.04 / 07.11 / 07.18 ( 총 5 회 ) VAC removal 2011.07.21

19. VAC (Vacuum assisted closure) - Fleischmann, 1993 년 최초 감염되거나 개방된 상처의 치료에 조절된 음압 (controlled subatmospheric pressure) 을 사용 - Argenta 와 Morykwas, 1997 년 국소적 음압을 2 차 치유에 의 해 상처 회복을 촉진시키는 하나의 방법으로 사용하면서 Wound VAC 장치를 발전 - suction canister, suction tube, polyurethane foam VAC advanced therapy system (ATS) Disease review

20. VAC (Vacuum assisted closure) - Negative pressure: intermittent mode, continuous mode (optimal pressure: 125 mmHg) - Polyurethane foam: 400-600 μ m 의 기공 크기. 삼출물을 제거하고 음압을 상처부위에 균일하게 분배. Foam sponge 는 치료가 끝날 때까지 매 48-72 시간마다 교환 Disease review

21. VAC (Vacuum assisted closure) - complex diabetic foot wounds, traumatic wounds, postoperative infected wounds or complex perineal wounds - 조직에 응력 (stress) 을 가하여 조직의 세포 분열과 성장인자 합 성을자극 부종을 형성하는 과도한 간질액을 적극적으로 배출시켜 미세 순환을 활성화 상처 내 세균의 수를 감소시켜 감염을 예방 - significant reduction in wound closure time, mild to moderate discomfort and possibly shorter hospitalization Disease review