순 환 기 내 과 R1 김 형 오 / prof. 김 우 식 왼쪽 어깨 통증을 주소로 내원한 27 세 여자 환자 MGR

Emergency Department Record 장 O 영 (27/F) ER visit time : AM 2:16 Chief Complaint Lt. Shoulder pain Recent o/s> 내원 1 일전 (2/18, pm8) Present illness PCOS, Cushing’s synd. s/p Lt. adrenalectomy(2011 년 ) 등으로 본원 OBGY, IE f/u 중인 27 세 여환, 최근 발생한 Lt. shoulder pain 이 점점 심해져서 Local OS 에서 X-ray 등 시행받고 이상소견 없어 observation 해오던 중, 내원 1 일전 저녁부터 Sx. Aggravation 되고 Pain 으로 인해 Dyspnea, chest discomfort 도 동반되어 응급실 내원함.

Emergency Department Record 3 응급의료센터 처치 사항 ER 에서 시행한 Lab(Cardiac marker, CRP 포함 ) 및 Lt. Shoulder X-ray, Chest X-ray, ECG 에서 이상소견 없었으며 Pain control(with IV injection) 에 Sx 호전되어 귀가 조치함. 응급실 퇴원약 PO NSAID(pain control), Muscle relaxant, GI protective agent AM 04:55 퇴실 Sx 악화시 OS OPD f/u 할 것을 Rec. 함.

Emergency Department Record 장 O 영 (27/F) ER visit time : AM 7:46 Chief Complaint Lt. Shoulder pain & Dyspnea Brief Hx Lt. Shoulder pain 으로 당일 새벽에 본원 응급실에서 처치받고 귀가했 던 환자로 귀가 후 Lt. Shoulder Pain 재발하고 epigastric pain 및 Dyspnea 동반되어 재내원함. 재내원 후 시행한 ECG, Chest X-ray, Cardiac marker 에서 이상소견없 음. Pain control 후에 가능성은 낮지만 Heart problem 가능성 설명 후 순 환기내과 외래로 Refer 함.

History 장 O 영 (27/F) adm. : Chief Complaint Lt. Shoulder pain Recent o/s> 내원 1 일전 (2/18, pm8) Present illness 27 세 여자, cushing's syndrome 으로 Lt adrenalectomy 2011 년도 시행하고 IE(Pf. 김성운 ) f/u 하며 현재 hydrocortisone 10mg po bid 투약받고 있는 환자 임. 평소 1 개월에 2~3 회 꼴로 Lt. shoulder pain 발생, 30 분 ~1 시간 지속되다 spontaneous resolution 되어왔던 환자로 1 일 전부터 Lt. shoulder pain 발생하 여 지속되고 있었으며 함께 epigastric pain, anorexia, nausea, vomiting 심하 여 식사 전혀 못하고 있었음. 1 일 전 local OS 방문하여 Lt. shoulder x-ray 촬 영하였으나 이상 없다는 소견만 듣고 별다른 조치 없이 귀가하였으며 통증 지 속되어 본원 ER 방문하여 shoulder x-ray 재촬영 하였으며 이상 없다는 소견 들음. Pain 심하여 ER 에서 귀가 불가능하여 순환기내과 외래 방문하여 evaluation 위해 입원함.

6 Past-medical history HTN/DM/Tbc/Hepatitis (-/-/-/-) PCOS (2010) Cushing’s syndrome Op. Hx Lt. adrenalectomy d/t Cushing’s syndrome, 2011 Drug history Drospirenone 3mg, ethinyl estradiol 0.02mg 1T qd Hydrocortisone 10mg 1T bid Familial Hx Non-specific Personal Hx alcohol (-), smoking (-)

Review of system 7 General : Fever (-), chills (-), fatigue(-), weight loss (-) Skin : Itching (-), bruises (-) HEENT : Headache (-), rhinorrhea (-), sore throat(-) Chest : C/S/R (-/-/-), dyspnea (+) Cardiac: Chest pain (-), palpitation (-), DOE (-) Lt. shoulder pain (+) GI: Abdominal pain (+) : Epigastric region A/N/V/D/C (+/+/+/-/-), hematochezia/melena (-/-) GU: Dysuria(-), urgency(-), frequency (-), hematuria(-) residual urine sensation (-), nocturia (-) Nerve system: Dizziness (-), sensory loss(-) 찌르는 듯한 양상 지속되는 통증 2 일간 3 회 Nausea 는 수시발생

Physical Examination 8 V/S : 110/70mmHg – 76/min – 20/min – 36.2 ℃ General : Alert, Acutely ill-looking appearance Skin : Rash (-), pigmentation(-), petechiae (-) HEENT : Isocoric pupil with PLR (++/++) no palpable neck mass, NVE (-), LNE(-) white sclera, pink conjunctiva Chest : Clear breathing sound without rale nor wheezing Regular heart beat without murmur Lt. chest wall tenderness (+) Abdomen : Soft and flat abdomen Normoactive bowel sound Td / rTd (+/-) : epigastric region Back & Extremities : CVA Td(-/-), Lt. shoulder pain(+) Pretibial pitting edema (-/-) Neurology : unremarkable Lt. arm immobility d/t pain

Initial Lab Finding (at ER) 9 CBC/DC) 9600/mm² g/dl – 11.7% - 358K (seg. 74.8%) Chemistry) TB/DB0.64/0.19mg/dlBUN/Cr8/0.4 mg/dl Prot/alb6.9/4.3 g/dLNa/K/Cl139/4.3/103 mg/dL AST/ALT19/9 IU/LCa/P/Mg9.0/3.5/2.1 mg/dL ALP/GGT60/10 IU/LCRP<0.3mg/dL CK73 U/L CK-MB/TnI0.4/0.00 ABGA) mmHg-89.3mmHg-22.5, 97.0% U/A) RBC 0-1 HPFWBC 0-1 HPFLeukocytes - Proteinuria (-)Urinalysis Occult Blood -

Initial Chest X-ray 10

Initial Simple Abdomen X-ray 11

Initial ECG 12

Initial Problem Lists 13 #1. Left shoulder pain #2. Epigastric pain #3. Dyspnea #4. Nausea & Vomiting #5. Known Cushing’s syndrome s/p Lt. adrenectomy #6. Known PCOS

14

Initial Assessment and Plan 15 #1. Left shoulder pain r/o musculoskeletal problem r/o cardiac origin radiating pain #2. Dyspnea r/o PTE r/o Pain-related dyspnea #3. Epigastric pain r/o AGE r/o GERD r/o Pancreatitis r/o ACS r/o Ruptured aortic aneurysm r/o Pericarditis r/o Pleuritis r/o Splenic abscess r/o Subdiaphragmatic abscess r/o Esophagitis

Initial Assessment and Plan 16 #4. Anorexia #5. Nausea #6. Vomiting r/o AGE r/o GI obstruction

Initial Assessment and Plan 17 #1. Left shoulder pain r/o Musculoskeletal problem Dx Plan) Shoulder X-ray Tx Plan) Pain control #2. Dyspnea r/o PTE r/o Pain-related dyspnea Dx Plan) Chest CT, D-dimer, ABGA Tx Plan) O2 supply if needed, pain control

Initial Assessment and Plan 18 #3. Epigastric pain r/o AGE r/o Acute appendicitis r/o Pericarditis r/o Pleuritis r/o ACS Dx Plan) EKG, Echocardiogram, Gastroscopy Abdomen X-ray, Abdomen CT, chest CT Tx Plan) CAG if needed, GS refer if needed r/o Ruptured aortic aneurysm r/o GERD r/o Esophagitis r/o Splenic abscess r/o Subdiaphragmatic abscess

Initial Assessment and Plan 19 #4. Anorexia #5. Nausea #6. Vomiting r/o AGE r/o GI obstruction Dx Plan)Abdomen X-ray, Abdomen CT, Tx Plan)Symptom control Gastroscopy

HD #1 (2013/2/19) S> Lt. shoulder pain, epigastric pain A/V/N/D/C(+/+/+/-/-) 변화없음 O> Echocardiogram : normal, EKG : NSR Shoulder X-ray : normal Lab : 특이소견 없음 CRP<0.3mg/dL, WBC 9600/uL, seg. neutrophil 74.8% A> r/o Musculoskeletal problem r/o GI problem P> Gastroscopy Shoulder X-ray 20

Shoulder X-ray ( )

Echocardiogram ( )

HD #2 (2013/2/20) S> Lt. shoulder pain, epigastric pain A/V/N/D/C(+/+/+/-/-) 변화없음 O> Left shoulder X-ray normal Lab : Leukocytosis : WBC 14570/uL, seg. neutrophil 83.9% No fever Abdomen CT Gastric fundus focal narrowing, EG junction dilatation Left pleural effusion, cannot rule out empyema A> r/o Pleural effusion r/o GI obstruction P> Chest CT L-tube drain, Gastroscopy 23

Abdomen CT ( ) 24

HD #3 (2013/2/21) S> Lt. shoulder pain, epigastric pain : 호전 없음 A/V/N/D/C(+/+/+/-/-) L-tube insertion 후 nausea, vomiting 해소 O> Lab: CRP 15.23mg/dL WBC 14570/uL, seg. neutrophil 90.3% No fever Chest CT r/o esophageal diverticulum with diaphragmatic hernia GE junction stricture, Left pleural effusion A> r/o esophageal diverticulum P> Antibiotics start : avelox TS consultation 25

Chest X-ray ( )

Chest CT ( )

EGD ( )

OP record Stomach strangulation d/t diaphragmatic hernia –Diaphragmatic repair –Proximal gastrectomy with esophago-jejunostomy with jejunojejunostomy

Final diagnosis Stomach strangulation d/t diaphragmatic hernia