호흡곤란을 주소로 내원한 65 세 남자 호흡기내과 R 1 김동현 / Prof. 박소영 MGR

박 O 진 (M/65) adm. : Chief complaint –Evaluation of operability for known lung cancer(SCC, T4N3M0(IIIB)) Present illness –M/65, 월 fall down 으로 SAH & SDH 발생하여 본원 신경외과 입원하여 OP 받았던 자로 당시 Chest X-ray 에서 이상 보여 시행한 CT 에 Rt lung mass 관찰되어 evaluation 후 squamous cell carcinoma(IIIB) 진단, chemotherapy #6 실시한 후 lung cancer operability evaluation 위해 내원함. History

Past Medical History DM/HTN/TBc/Hepatitis(-/+/-/-) –HTN 3 년전 진단, Dilatrend 12.5mg qd Op Hx(+) –‘08 10/14 Craniotomy c hematoma evacuation d/t SDH & SAH

Personal History Alcohol : 과거 음주 – 소주 1 병씩, daily, lung cancer 진단 후 금주. Smoking : 과거 흡연 –40 pack year, lung cancer 진단 후 금연. Family History None

Review of System 1. General Generalized weakness(-) Fever(-) Chill(-) Myalgia(-)Weight change(+) 6kg during 1month 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(+) frontal Dizziness(-) Otalgia(-) Otorrhea(-)PND(-)Nasal obstruction(-) Rhinorrhea(-)Sore throat(-)Swallowing difficulty(-) 4. Respiratory Dyspnea(+) : MRC Gr II Cough(-)Sputum(-) Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)DOE(-) Palpitation(-)

6. Abdominal A/N/V/D/C(-/-/-/-/-) Dysphagia(-) Bowel habit change(-) Abd. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(-) Swelling(-) Tenderness(-) Backpain(-) Myalgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Review of System

Physical Examination Height : 162 cm Weight : 65 kg BMI : 24.8 kg/m 2 Vital Sign : 130/70 mmHg - 86/min - 20/min ℃ 1. General appearance Alert consciousness Chronic-ill looking appearance 2. Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 3. E/ENT Isocoric pupil c PLR(++/++) Pinkish conjunctiva, Mildly icteric sclera Pharyngeal injection(-), PTH(-/-)

Physical Examination 4. Chest Symmetric chest expansion Decreased BS on Rt lung field without rale and wheezing Regular Heart Beat without ⓜ 5. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-), Hepatomegaly(-) 6. Back&extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-) 7. Motor, sensory : intact

Initial Lab Finding 1.CBC/DC 7000 / ㎕ – 12.4 g/ ㎗ % - 263,000 / ㎕ (seg : 71.3%) aPTT 38.9 sec PT INR 1.00 % 2.Chemistry TB / DB0.55/ 0.17 mg/ ㎗ BUN/Cr8 / 0.6 mg/dL Protein/Albumin7.3 / 4.6 g/ ㎗ Na/K/Cl 137 / 4.7 / 96 mEq/L AST/ALT21 / 20 U/L Ca/P/Mg 9.3 / 3.6 / 2.1 mg/dL ALP/rGT87 / 21 U/L Uric acid6.1 mg/dL CRP 1.0 mg/dL 3.UA RBC 0~1 /HPF WBC 0~1 /HPF Blood - Protein - Glucose - Bilirubin -

Initial Chest PA

Initial ECG

#1. NSCLC (SCC Stage IIIB) s/p CbTx #6 #2. Known HTN #3. Past SDH & SAH s/p craniotomy & hematoma evacuation Initial Problem Lists

#1. NSCLC (SCC Stage IIIB) s/p CbTx #6 1) Dx - Operability check : PFT / Lung perfusion scan if needed : Chest CT to evaluate disease extent 2) Tx - Lobectomy if operation is possible - Adjuvant CTx or RTx if needed Initial Assessment and Plan

#2 HTN 1) 기존 dilatrend 유지. #3 SDH & SAH s/p craniotomy & hematoma evacuation 1) 기존 신경외과 약물 복용유지. Initial Assessment and Plan

Clinical Course

Clinical Course – Before OP ‘08‘09 #1 12/11 #2 12/30 #3 1/21 #4 2/11 #6 3/25 #5 3/4 Before CTx After CbTx #6 Before OP Pre-OP PFT FEV11.83 L Lung Perfusion Scan Post OP FEV1 : 1.44 L RightLeft Upper Middle Lower Total

Clinical Course – Before OP ‘08‘09 #1 12/11 #2 12/30 #3 1/21 #4 2/11 #6 3/25 #5 3/4 OP 9/1 1. Operation - Bilobectomy, RUL & RML - MLD, Adhesiolysis - Pericardiotomy and primary closure 2. Pathology - Squamous cell carcinoma - Pathologic stage stage IIIB (pT4N2)

Clinical Course – After OP C/T tip S. epidermidis (MRCNS) C/T tip S. Hominis (MSCNS) 9/29/89/149/20 9/26 10/1 10/7 Flomoxef

S> –Dyspnea (Saturation 이 70% 까지 떨어지기도 함 ) –Cough (+) / Sputum (+) : purulent O> –V/S : 110/60 mmHg – 20/min – 100/min – 36.6 ℃ –WBC : 9640 (seg:82.4%) / CRP : 19.8 (2.3 → ) –ABGA : – 49.8 – 61.4 – 91.9% (Nasal prong 5L/min) A> –r/o pneumonia (HAP) P> –Antibiotics : Flomoxef d/c & Teicoplanin start –O 2 supply –I/O Control –Fever study (Blood, Sputum etc.) Progression Note - POD #13(09/14) 9/13(POD#12)9/11(POD#10)

S> –Dyspnea aggravation O> –V/S : 110/60 mmHg – 30~40/min – 156/min – 36.1 ℃ –WBC : 9400 (Seg:81.9%) / CRP : 19.5 –ABGA : – 60.4 – 63.2 – 33.1 – 90.7% (Venturi 0.5 / 15L/min) –PaO2/FiO2 : A> –ARDS r/o d/t pneumonia (HAP) P> –Antibiotics alteration (add Levofoxacin d/t Stenotrophomonas maltophilia ) –O 2 supply (Venturi → Recommend ETMV → NIPPV d/t refuse) –I/O Control Progression Note - POD #16(09/17) 9/14(POD#12) 9/17(POD#16)

Clinical Course – After OP 9/29/89/149/20 9/26 10/1 10/7 Flomoxef Levofloxacin Teicoplanin NIPPV 0.5/15 ABGA - Before NIPPV : mmHg mmHg mmol/L % - Aftre 1hr : mmHg mmHg mmol/L % - After 2hr : – 48.8 mmHg – mmHg – 30.8 mmol/L – 99.0 %

Clinical Course – After OP 9/29/89/149/20 9/26 10/1 10/7 Flomoxef Levofloxacin Teicoplanin NIPPV 0.5/15 Steroid 9/21 IP 전과 9/17(POD#16) 9/21(POD#20)

S> –Dyspnea (-) / Cough (-) / Sptum (+) : decreased amount/whitish O> –V/S : 130/80 mmHg – 20/min – 131/min – 36.4 ℃ –WBC : (seg:87.8%) / CRP : 0.6 –ABGA : – 69.2 – – 39.1 – 99.3% (NIPPV 15L/min) → – 79.3 – 96.3 – 40.1 – 97.4% (Venturi 0.5 / 15L/min) ( PaO2/FiO2 : ) A> –ARDS improving state r/o d/t pneumonia (HAP) P> –Antibiotics maintenance (Teicoplanin + Levofoxacin) –O 2 supply tapering (NIPPV → Venturi ) & steroid tapering –I/O Control Progression Note - POD #28 (09/29) NIV withdrawal criteria - Blood gas values and clinical condition improved significantly with no sign of respiratory distress, - Respiratory rate < 25 breaths/min, - PaO2 > 60 mmHg on air or PaO2/FiO2 > 250 mmHg while breathing any supplemental oxygen - pH < 7.35 during at least a 24hr period. Intensive Care Med (2009) 35:663–670

Clinical Course – After OP 9/29/89/149/20 9/26 10/1 10/7 Flomoxef Levofloxacin Teicoplanin NIPPV 0.5/15 Steroid 9/21 IP 전과 9/21(POD#20)9/29(POD#28)

Clinical Course – After OP 9/29/89/149/20 9/26 10/1 10/7 Flomoxef Venutri → Nasal prong Levofloxacin Teicoplanin NIPPV 0.5/15 Steroid Levofloxacin Teicoplanin Steroid tapering 9/29(POD#28) 10/7(POD#36)

Clinical Course – After OP 9/29/89/149/20 9/26 10/1 10/7 Flomoxef Venutri → Nasal prong NIPPV 0.5/15 Levofloxacin Teicoplanin Steroid HRCT

Clinical Course – After OP 9/2 9/149/209/26 10/1 10/7 Flomoxef Venutri → Nasal prong(to 0.5L/min) 0.5/15 Steroid tapering (240 →5) 9/8 10/23 Teicoplanin Levofloxacin NIPPV HRCT 10/7(POD#36) 10/23(POD#52)10/02/25

Acute Respiratory Distress Syndrome due to hospital acquired pneumonia Final Diagnosis