소화기내과 R1 황진경

Case 1 Case M/65 정 O 창 Admission ’ Chief complaint 조기위암 Onset Onset ‘09.12 월 Present illness 03 년 3 월 본원에서 진행성위암, 직장암으로 수술 받고 항암치료, 방 사선치료 받았음. 그 후 타 병원에서 추적 관찰 중 2009 년 12 월 추적 위내시경에서 조기위암 진단받고 치료 위해 입원함.

Past Medical History HTN/DM/Tuberculosis/Hepatitis (+/+/-/-) HTN/DM : medication 간헐적으로 하다 현재는 복용하지 않은 상태임 Atrial fibrillation (+): aspirin 복용 중 Operation History ’03 년 AGC -> STG Bilroth I op at KMC ’03 년 rectal cancer -> LAR + adjuvant CRTx at KMC ’08 년 sigmoid adenocarcinoma -> AR at 동국대학교 병원 Personal History Smoking (-) Alcohol (-)

Review of Systems General fever (-) chill (-) fatigue (-) wt change (-) Head/ENT headache (-) neck stiffness (-) sore throat (-) Repiratory cough/sputum/rhinorrhea (-/-/-) dyspnea (-) hemoptysis (-) Cardiovascular chest pain (-) palpitation (-) DOE (-) GI A/N/V/D/C (-/-/-/-/-) abdominal pain (-) melena (-) hematochezia (-) hematemesis (-) Urogenital urgency (-) frequency (-) tenesmus (-) Neuromuscular numbness (-) dizziness (-) syncope (-) seizure (-)

Physical Examination Initial V/S 120/80 mmHg-80 /min-20 /min-97% General alert consciousness chronic ill-looking appearance Head/ENT isocoric pupil c pupil light reflex (++/++) whitish sclera/pale conjunctiva neck vein engorgement (-/-) neck lymph node enlargement (-/-) Chest symmetric chest expansion regular heart beat without murmur clear breathing sound without rale or wheezing Abdomen soft and flat abdomen normoactive bowel sound abdominal tenderness/rebound tenderness (-/-) Back/Ext costovertebral angle tenderness (-/-) pretibial pitting edema (-/-)

Initial Lab Findings CBC/DC 3, g/dL-28.2% PT 14.5 sec (INR 36.6%)/ aPTT 1.10 sec Chemistry TB/DB 0.53/0.20 mg/dL BUN/Cr 16/0.1 mg/dL ALP/rGT 69/14 U/L Na/K/Cl 141/4.0/0.9 mmol/L Prot/Alb 5.9/3.7 g/dL Glucose 102 mg/dL AST/ALT 18/16 U/L Ca/P/Mg 7.5/3.1/2.1 mg/dL CRP <0.3 mg/dL LD/CK 203/118 U/L Iron 15 ug/dL TIBC 437 ug/dL Urinalysis RBC 0~1 /HPF WBC 2~4 /HPF

Initial Problem lists #1. Known Early gastric cancer #2. Iron deficient anemia #3. s/p STG Bilroth I d/t stomach cancer (‘03) #4. s/p LAR + CRTx d/t rectal cancer (‘03) #5. s/p AR d/t sigmoid cancer (‘08)

Work-up ‘ Gastroscopy Colonoscopy ‘ Abdomen CT Chest CT ‘ PET CT ‘ ESD

EGD

EGD

EGD

EGD

2007, M/55, STG B-1, EGC

2007, M/72, EGC, Wedge R

2009, M/68, EGC, STG-B-1

GI Conference

Chief Complaint 대장 궤양 os) 2008 년 8 월 Present Illness 특이 병력 없는 ４８세 남자로 ０８년도 ８월, ０９년도 ４월 두 차례 타 병원에서 대장내시경 시행 하여 하행 결장에 궤양을 진단 받았으나 특별히 치료 받지 않고 지내다가 금년 본원에 치료 받기 위해 내원함 임 O 원 (M/48) OPD visit date :

Past medical history DM / HTN / Tbc / Hepatitis (-/-/-/-) Op Hx (-) Drug Hx (-) Family history none Personal history Smoking (?) Alcohol (?) 21

General fever(-) chill(-) sweat(-) weight loss(-) Skin rash (-) itching (-) Head & Neck headache (-) stiffness (-) Respiratory cough (-) sputum (-) dyspnea (-) Cardiac chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal A/N/V/D/C (- / - /- / - /- ) abdominal pain (-) dyspepsia (+) Urinary dysuria (-) frequency (-) urgency (-) Musculoskeletal weakness (-) numbness (-) Nervous syncope (-) seizures (-) dizziness (-) 22 Review of System

Physical Examination 23

Initial Lab Findings CBC/DC g/dL – 48.2% - 319k (seg. 64.3%) PT INR 0.97 a PTT 32.6 Chemistry TB/DB 0.641/0.21 mg/dL CRP 0.79 mg/dL ALP/rGT 92/87 IU/L Ca/P/Mg 9.0/6.3/2.4 mg/dL AST/ALT 21/24 IU/L Uric acid 5.2 mg/dL Prot/Alb 7.6/4.5 g/dL LD/CK 343/51 U/L BUN/Cr 11/0.9 mg/dL T- cholesterol 125 mg/dL Na/K /Cl 133/3.3/98 mmol/L Glucose 108 mg/dL UA RBC 0~1, WBC 0~1

C-ANCA (-) P-ANCA(-) ANA (-) anti-CMV Ig M (-), IFN-γ (-) Tumor marker

Problem list Known colonic ulcer

Work up Gastroscopy (3/23) Colonoscopy (3/23) Abdomen CT (3/23)

Chief Complaint 뒤무직 os) 내원 2 주전 Present Illness ５６세 여자로 내원 ３주 전에 울릉도 여행 다녀 온 뒤부터 오심과 복통, 뒤무직 발생하여 개인의원 방문 함. 대장 내시경에서 궤양성 대장염 의심되어 약물치료 하 였으나 증상 지속되어서 내원함 홍 O 묘 (F/56) Admission date : 2009/11/10 CASE 2 28

Past medical history DM / HTN / Tbc / Hepatitis ( - / - / - /- ) Drug Hx (-) Op Hx (+) 월 : hemorrhoidectomy Family history none Personal history Smoking (-) Alcohol (-) Food Hx: 3 주 전 회와 오징어 섭취 29

General : fever (-) chill (-) fatigue (-) weight loss (-) Skin : rash (-) itching (-) Head & Neck : headache (-) stiffness (-) Respiratory : cough (-) sputum (-) dyspnea (-) Cardiac : chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal : A/N/V/D/C (+/+/-/+/-) 3~4 회 loose stool abdominal pain (+) diffuse, intermittent Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 30 Review of System

Physical Examination Vital sign 120/80 mmHg – 70 회 /min – 20 회 /min – 36.9°c General alert consciousness Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclerae not pale conjunctivae Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and flat abdomen hyperactive bowel sound tenderness (-) rebound tenderness (-) no rigidity no guarding no palpable mass 31

Initial Lab Findings CBC/DC 8,370/mm 3 – 11.3 g/dl – 34.7% - 505k (seg. 74.1%) PT 13.7 INR 1.04 a PTT 25.5 Chemistry TB/DB 0.39/0.2 mg/dL CRP: 10.5 mg/dL ALP/rGT 73/49 IU/L Ca/P/Mg 8.2/2.8/2.4 mg/dL AST/ALT 20/18 IU/L Uric acid 3.2 mg/dL Prot/Alb 6.4/3.5 g/dL LD/CK 545/67U/L BUN/Cr 8/0.97 mg/dL T-cholesterol 134 mg/dL Na/K /Cl 140/4.2/99 mmol/L Glucose 105 mg/dL UA RBC 0~1 WBC 0~1

Anti-CMV IgM (-), Anti-CMV IgG (+) 결핵균 특이항원 (IFN-γ) (-) Ig G, RA factor, Ig A, Ig M, Ig E, C3, C4: normal range C-ANCA (-) P-ANCA(-) ANA (-) Helminth (-), Protozoa (-)

Problem list Infectious colitis R/O Ulcerative colitis

Work up) Sigmoidoscopy ( ) Pelvic CT ( ) Pevic angio 3D CT ( ) F/U Sigmoidoscopy ( /11. 27/ / )

GS-GI Conference Case 1

C.C) Stool caliber change (o/s : 4 개월 전 ) P.I) HTN 으로 po med. 하는 자로 4 개월 전부터 stool caliber change 있어 09 년 4 월 11 일 타 병원에서 시행한 colonoscopy 에서 rectal ca. 진단 받고 본원에서 시행한 abd. CT 에서 sacral metastasis 있어 09 년 4 월 21 일부터 09 년 5 월 20 일까지 neoadjuvant CTx & RTx 시행 후 op 위 해 본원 외과 내원. PMHx) HTN/DM/Hepatitis/Tbc (+/-/-/-): 03 년 진단, po med. PHx) alcohol(+): 2 회 / 주, 소주 1 병 smoking(+): 37 pack-year OP Hx) (-) 백 O 현 M/63

ROS) 1. General : fever(-), chill(-), poor oral intake (-) 2. H&N : headache(-), hearing disturbance (-) 3. Skin : rash(-), itching (-) 4. Chest : dyspnea (-), C/S/R(-/-/-) 5. Cardiac : chest pain(-), palpitation(-) 6. GI : abd.pain(-), A/N/V/D/C(-/-/-/-/-), abd.discomfort(-) : hematochezia(-), melena(-) stool caliber change(+) 7. Urinary : dysuria(-), frequency(-) 8. Nervous : syncope(-)

P/Ex) 1. General alert mentality, chronic ill looking appearance 2. H&N isocoric pupil c PLR(++/++) NVE (-/-), LNE(-/-) 3. Chest symmetric chest expansion CBS s rale, whizzing RHB s murmur 4. Abdomen soft & flat abdomen normoactive bowel sound Td/RTd (-/-) DRE(+): AV 상방 2cm 부터 ulcerofungating mass 촉지 5. Back/Ext CVA Td(-/-) Pitting edema (-/-) 6. Neurology sensory & motor : intact

Initial lab) CBC/DC : 8360 – 9.2 – 29.7 – 522K (seg : 80.4%) PT : 13.5 sec (1.02 INR), aPTT : 39.5 sec Chemistry TB/DB : 0.25/0.09, prot/alb : 7.2/3.7, AST/ALT: 17/15 BUN/Cr : 9/0.7, Na/K/Cl : 138/3.8/102, U/A RBC : 0~1, WBC : 0~1 Chest PA no active lung lesion

W/U) sigmoidoscopy Abd CT Pelvis CT

Imp) Renal Ca c bladder invasion c sacral metastasis Op) Total pelvic exenteration with sacrectomy (OS 에서 시행 ), APR(Abdominoperineal resection), prostatectomy, cystectomy