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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
  • 2011.04.05 cough, yellowish sputum 증가dyspnea aggravation  충주의료원 방문 Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원
  • 2011.04.06 Foley catheter insertion
  • 2011.04.07 insomnia, hallucination 및 말이 많아지는 양상 보임
  • 2011.04.09 스스로 line remove 하려고 하며 irritability 발생 ABGA 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/S 140/83mmHg - 108- 24- 36℃
  • G/A Chronic ill-looking appearance
  • Mentality Alert & well orientation
  • HEENT not anemic conjunctivae, anictericsclerae

Dehydrated tongue (-) PNS tenderness(-)

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

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

  • Chest Symmetric chest expansion

Iregularheart beat w/o murmur

Clean breathing sound w/o wheezing

physical exam1
Physical Exam
  • Abdomen Soft & 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 (-)

slide11
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
  • BUN 21 mg/dL
  • Cr 0.92 mg/dL
  • BUN/Cr 23.0
  • CRP▲ 4.06 mg/dL
  • Na 140 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
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%
ad