1. Case Presentation
2010/ 03/15

2. Constipation os) 내원 2개월전 Present Illness
CASE 1
M/ 김 O 준
Admssion date :
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

3. 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

4. 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

5. 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

6. Initial Lab Findings CBC/DC
6050/mm² g/dL – 28.6% -367k (seg 60.8%)
PT INR a PTT 34.2
Chemistry
TB/DB /0.14 mg/dl CRP:<0.3mg/dL
ALP/rGT / IU/L
AST/ALT / IU/L
Prot/Alb / g/dL
BUN/Cr / mg/dL
Na/K/Cl /4.0/ mmol/L
TIBC 369 ug/dL
s-iron 11 ug/dL
CA U/mL
AFP ng/ml
CEA ng/ml
FeUrea prerenal type
FeNa 0.07

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

8. IMP) Rectal cancer c r/o colon cancer

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

10. CASE 2 Chief Complaint Rt flank pain os)2010/01/29 Present Illness
F/ 김 O 숙
Admssion date:
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

11. 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

12. 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

13. Physical Examination
Vital sign /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

14. Initial Lab Findings CBC/DC
10720/mm² g/dl – 37.5% - 525k (seg 60.5%)
PT INR a PTT 42.8
Chemistry
TB/DB 0.44/ mg/dL CRP 5.50 mg/dL
ALP/rGT / IU/L LD/CK 450/34 U/L
AST/ALT / IU/L Amylase/Lipase 79/73 U/L
Prot/Alb / g/dL
BUN/Cr / mg/dL
Na/K/Cl /4.3/100 mmol/L
CA U/mL
AFP ng/mL
CEA ng/mL
CA U/mL
FeUrea prerenal type
FeNa 0.07

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

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

17. 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

18. Creatinine 24h (U) 0.87g
Cortisol(U) ㎍/day
ACTH(P) 52.2 pg/ml
Cortisol(S) 24.4 ug/dL
Aldosterone(S) pg/ml
PRA (P),Renin 2.4 ng/ml/hr
VMA(U) mg/day
Norep(P) ng/mL
Norep(U) 45.1 ㎍/day
Epine(P) ng/ml
Epine(U) ug/day
Meta(U) mg/day

19. GS-GI Conference
Case 1

20. 전O영 F/35
C.C) RLQ pain (o/s : 월 부터) P.I) 특이 병력 없는 자로 월부터 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.

21. 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(-)

22. 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

23. TB/DB : 0.36/0.18, prot/alb : 8.0/4.4, AST/ALT: 15/10
Initial lab)
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

24. W/U) Abd.CT Pelvic MRI

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

26. Case 2

27. 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

28. 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(-)

29. 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

30. TB/DB : 0.59/0.16, prot/alb : 7.2/3.9, AST/ALT: 9/7
Initial lab)
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 : CA19-9 :
U/A
RBC : 0~1, WBC : 2~4
Chest PA
r/o bronchial disease on LLLZ

31. W/U) 2009. 11. 26 Low dose Chset CT(검진) 2009. 12
W/U) Low dose Chset CT(검진) Gastroscopy Colonoscopy Pelvic CT Pelvic MRI PET-CT

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