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Case Presentation . 성균관대학교 의과대학 2007313075 손의영. Chief Complain. 김 O 식 , M/83 Dyspnea Onset : 2 weeks ago. Present Illness. 2011.02 TB pleurisy 로 치료 받은 후에 간헐적으로 dyspnea 호소 2000.03.09 Pneumonia w/ respiratory failure 로 입원 후 치료받고 퇴원 2009. 우울증 진단 후 1 년간 medication 복용

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Case presentation

Case Presentation

성균관대학교 의과대학

2007313075 손의영


Chief complain

Chief Complain

  • 김O식, M/83

  • Dyspnea

    • Onset : 2 weeks ago


Present illness

Present Illness

  • 2011.02 TB pleurisy로 치료 받은 후에 간헐적으로 dyspnea호소

  • 2000.03.09 Pneumonia w/ respiratory failure로 입원 후 치료받고 퇴원

  • 2009.우울증 진단 후 1년간 medication 복용

  • 이후 1년에 약 1차례 씩 감기로 인한 dyspnea로 입원 치료 함


Present illness1

Present Illness

  • 2011.04.05cough, yellowish sputum 증가dyspnea aggravation  충주의료원 방문Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원

  • 2011.04.06Foley catheter insertion

  • 2011.04.07insomnia, hallucination 및 말이 많아지는 양상 보임

  • 2011.04.09스스로 line remove 하려고 하며 irritability 발생ABGA 7.388 – 65.1 – 65.2 – 38.4 SpO2 91.7%CO2 retention aggravation 되어 보호자가 원하여 본원 내원


Other history

Other History

  • PMHx.

    • HTN/DM/Tb/hepatitis/Allergy ( + / + / - / - / - )

    • 약물력

      • Drugs for Depression (During 1 hour)

      • 2011.04.05. : ciprofloxacin, Tazobactam, Erythromycin

      • 2011.04.10. : Tazobactam, Levofloxacin으로 항생제 변경

    • 수술력

      • 없음

  • FHx.

    • 특이사항 없음

  • SHx.

    • Smoking: ex-smoker 30PA (30yr x 1 pack)


Review of system

Review of system

  • GW / EF ( + / + )

  • Weight change ( - )

  • Fever / chill ( - / - )

  • Headache / dizziness ( - / - )

  • Rhinorrhea / cough/ sputum ( - / + / + ) : yellowish

  • Dyspnea (+) : ATS grade III

  • chest pain / palpitation ( - / - )

  • Anorexia / nausea / vomiting ( - / - / - )

  • abdominal pain / discomfort ( - / - )

  • Constipation / diarrhea ( - / - )

  • Hematemesis / melena / hematochezia( - / - / - )

  • Urinary Sx( - )

  • Arthralgia( - )

  • Myalgia( - )


Physical exam

Physical Exam

  • V/S140/83mmHg - 108- 24- 36℃

  • G/AChronic ill-looking appearance

  • MentalityAlert & well orientation

  • HEENTnot anemic conjunctivae, anictericsclerae

    Dehydrated tongue (-) PNS tenderness(-)

    PTH/PI (-/-) JVP (-) Neck VE (-)

    Cervical LNE (-/-) Thyroid enlagement (-)

  • ChestSymmetric chest expansion

    Iregularheart beat w/o murmur

    Clean breathing sound w/o wheezing


Physical exam1

Physical Exam

  • AbdomenSoft & flat

    Bowel sound – normoactive

    No tenderness/rebound tenderness

    No shifting dullness

  • Back No CVAT

  • Extremities Skin rash(-)Clubbing (-)

    Joint ROM limitation (-)

    Joint swelling & stiffness (-)

    Joint deformity (-)


Spirometry ekg

Spirometry / EKG


Imaging

Imaging


Case presentation

Lab

  • WBC▲ 11.25 x10³/μL

    • Neut.▲ 92.2% (seg.)

    • Eo.0.1%

  • RBC▼ 3.80 x10³/μL

  • Hb▼ 11.3 g/dL

    • Hct▼ 36.1%

  • PLT262,000/μL

  • Protein▼ 4.2 g/㎗

  • Albumin▼ 2.7 g/㎗

  • Globulin▼1.5 g/㎗

  • AST35 U/l

  • ALT37 U/l

  • ALP 77 U/l

  • BUN21 mg/dL

  • Cr 0.92 mg/dL

  • BUN/Cr23.0

  • CRP▲ 4.06 mg/dL

  • Na140 mmol/ℓ

  • K▼3.4 mmol/ℓ

  • Cl▼ 96 mmol/ℓ


Problem list assessment

Problem List / Assessment

  • Problem List

    • #1. Dyspnea

    • #2. Depression

    • #3. Mania

    • #4. Aggravation of Coughand Sputum

    • #5. CO2 retention

    • #6. Leukocytosis

    • #7. increased CRP

  • Assessment

    • #1, 4, 5, 6, 7 : R/O Acute Exacerbation of COPD

    • #2, 3 : Bipolar disorder


Ae of copd etiology

AE of COPD – Etiology

  • Primary

    • Tracheobronchial infection

    • Air pollution

  • Secondary

    • Pneumonia

    • Pulmonary embolism

    • Pneumothorax

    • Rib fracture / Chest trauma

    • Inappropriate use of sedatives, narcotics, β-blocking agents

    • Right and/or Left heart failure or arrhythmias


Ae of copd

AE of COPD –


Lung cancer px

Lung cancer – Px

  • Non-small lung cancer의 Stage에 따른 예후

    • Stage IA :MSD 60개월 / 5YSR 50%

    • Stage IB : MSD 43개월 / 5YSR 43%

    • Stage IIA: MSD 34개월 / 5YSR 36%

    • Stage IIB:MSD 18개월 / 5YSR 25%

    • Stage IIIA: MSD 14개월 / 5YSR 19%

    • Stage IIIB: MSD 10개월 / 5YSR 7%

    • Stage IV : MSD 6개월 / 5YSR 2%


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