Case Presentation Division of Gastroenterology R2 김 지 연

Chief Complaint for TACE Present Illness F/ 년 B-viral LC with esophageal varix 진단 받은 환자로, 이후 esophageal varix 에 대해 3 차례 EVL 시행한 과거력 있으며 2008 년 HCC 진단 받고 금일 TACE 1 차 시행 위해 내원함 유 O 봉 F/61 Admission on

Past medical historyPast medical history DM / HTN / Tbc. ( - / - / - ) Hepatitis B (+) : entecavir 복용중 op Hx (-) Family history none Personal history Smoking (-) Alcohol (-)

Review of System General fatigue (-) chill (-) febrile sense (-) weight change (-) Skin rash (-) itching (-) pigmentation (-) Head & Neck headache (-) Eye & ENT visual disturbance (-) tinnitus (-) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

Review of System Gastrointestinal A/N/V/D/C (-/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) urgency (-) RU sense (-) flank pain (-) Musculoskeletal pain (-) backache (-) weakness(-) swelling(-) edema (-) Neurologic syncope (-) seizure (-) dizziness (-) numbness (-)

Physical Examination Vital sign 130/80 – 70 회 /min – 20 회 /min – 36.2°c kg/m 2 weight : 78kg height : 154cm BMI : 32.9 kg/m 2 General alert consciousness chronically ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT isocoric pupil with PLR (++/++) whitish sclerae pinkish conjunctivae PI (-) PTH (-/-)

Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft but distended abdomen normoactive bowel sound no tenderness / no rebound tenderness no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-)

Initial Lab Findings CBC/DC 4,160/mm² g/dl – 37.5% - 55K (seg 75.3%) PT (INR) 1.68 aPTT 45.1Chemistry TB/DB 0.41/0.14 mg/dL AST/ALT 34/31 IU/L ALP/GGT 93/60 IU/L Prot/Alb 6.7/3.8 g/dL BUN/Cr 13/0.6 mg/dL CRP <0.5 mg/dL Na/K/Cl 139/3.6/103 mmol/L Ca/P/Mg 8.5/3.2/2.0 mg/dL T-chol 147 mg/dLU/A RBC 0-1/HPF WBC 0-1/HPF Blood (-) Protein (-) Glucose (-) SG 1.015

Initial Problems HCC B-viral LC with esophageal varix s/p EVL #3 1. HCC → TACE #1 2. B-viral LC with esophageal varix s/p EVL #3 Plans

TACE #1 시행 TACE #1 시행 Clinical Course

Chief Complaint for Radiotherapy Present Illness M/ 년 B-viral LC 진단 받고 2005 년 HCC 진단 후 TACE 10 차 까지 시행 받았던 환자로, 2008 년 9 월 시행한 chest CT 상, rib metastasis 소견 보여 Radiotherapy 시행하였다가 neutropenia 소 견 보여 총 15 회 중 6 회까지 시행하고 discharge 하였다가 추가 Radiotherapy 시행 위해 내원함 임 O 수 M/53 Admission on

Past medical historyPast medical history DM / HTN / Tbc. ( - / - / - ) Hepatitis B (+) op Hx (-) Family history none Personal history Alcohol (-) : 2005 년부터 금주. Smoking (-) : ex-smoker (30 년전부터 stop)

Review of System General fatigue (-) chill (-) febrile sense (-) weight change (-) Skin rash (-) itching (-) pigmentation (-) Head & Neck headache (-) Eye & ENT visual disturbance (-) tinnitus (-) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

Review of System Gastrointestinal A/N/V/D/C (-/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) Urinary Urinary dysuria (-) frequency (-) urgency (-) RU sense (-) flank pain (-) Musculoskeletal pain (-) backache (-) weakness(-) swelling(-) edema (-) Neurologic syncope (-) seizure (-) dizziness (-) numbness (-)

Physical Examination Vital sign 110/80 mmHg - 70/min – 20/min – 36.6°C kg/m 2 weight : 56kg height : 160cm BMI : 21.9 kg/m 2 General alert consciousness chronically ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT isocoric pupil with PLR (++/++) white sclera pink conjunctiva PI (-) PTH (-/-)

Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and flat abdomen normoactive bowel sound no tenderness / no rebound tenderness no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-)

Initial Lab Findings CBC/DC 1,820/mm g/dL – 32.7%- 47K (75.3%) PT (INR) 1.31 aPTT 37.9Chemistry TB/DB 1.16/0.48 mg/dL AST/ALT 44/24 IU/L ALP/GGT 73/26 IU/L Prot/Alb 7.7/3.5 g/dL BUN/Cr 12/0.9 mg/dL CRP <0.5 mg/dL Na/K/Cl 135/4.2/101 mmol/L Ca/P/Mg 8.8/3.3/2.1 mg/dLU/A RBC 0-1/HPF WBC 0-1/HPF Blood (-) Protein (-) Glucose (-) SG 1.015

Initial Problems and Plans HCC with metastasis to Lt.5 th &6 th ribs s/p TACE #10 s/p RTx.(~D6) B-viral LC (Child A) with esophageal varix s/p EVL # s/p neutropenia → consult for RTx. → CBC/DC f/u to check neutropenia → check liver CT f/u → consider EVL

Follow up liver CT on Follow up liver CT on → Aggravation of multiple HCC RTx. 시행 중 (D2) RTx. 시행 중 (D2) Clinical Course