Case conference 순환기 내과 R1 김 지 연 jaundice, abdominal discomfort 를 주소로 내원한 61 세 남자 환자

고 O 현 (M/61) Visit OPD on C.C ) O/S) 내원 4 일전 C.C ) jaundice, abdominal discomfort O/S) 내원 4 일전 P.I ) P.I ) 61/M, 평소 특이병력 없이 지내다가 내원 2 달전부터 가시오가 피 한달간 복용한 Hx. 있으며, 내원 4 일전부터 anorexia, jaundice & abdominal discomfort 있어 개인병원에서 acute viral hepatitis 의심하에 본원 소화기내과 외래 통해서 입원.

PMHx ) DM / HTN / TB / HEPATITIS ( - / - / - / - ) DM / HTN / TB / HEPATITIS ( - / - / - / - ) operation Hx ( + ) : 86 년 open cholecystectomy d/t GB stone operation Hx ( + ) : 86 년 open cholecystectomy d/t GB stone drug Hx.(+) : 2 개월전 가시오가피 1 달간 복용 FHx ) none PHx ) Alcohol ( - ) Alcohol ( - ) Smoking ( - ) Smoking ( - )

Review of System General : fatigue(-) edema(-) weight loss(+):3kg /3 개월 Skin : rash(-) pigmentation(-) Itching(-) Head & Neck : headache(-) stiffness(-) Eye & ENT : sore throat(-) periorbital edema(-) Respiratory : cough(-) sputum(-) dyspnea(-) Cardiac : palpitation(-) chest discomfort(-) orthopnea(-) Gastrointestinal: A/N/V/D/C(+/-/-/-/-) abdominal discomfort(+) jaundice (+) melena (-) Urinary : dysuria(-) frequency(-) urgency(-) Musculoskeletal: myalgia(-) weakness(-) numbness(-) Endocrine : polydipsia (-) polyuria(-) cold intolerance(-) Nervous : Syncope(-) seizures(-) dizziness(-) stroke(-) tremor(-)

Physical Examination Bwt :72kg Ht:174.3cm BMI:23.7kg/m 2 V/S) 120/ ℃ (SaO2: 97%) 1.General appearance - Consciousness : alert - Acutely ill looking appearance 2.Skin - No rash No pigmentation 3. Head & Neck - No neck vein engorgement - No cervical lymphnode enlargement 4.Eye/ENT - Isocoric pupil c PLR (++/++) - yellowish sclerae pinkish conjunctivae

Physical Examination 5.Thorax - Clear breathing sound without rale - Regular heart beat without murmur 6. Abdomen - Soft & flat abdomen - Normoactive bowel sound - No tenderness, No rebound tenderness - No hepatosplenomegaly 7.Back/ Extremity - No CVA tenderness - No pretibial pitting edema 8. Neurology - No flapping tremor motor sensory V V V V 100

CBC/DC ) 7,700 /mm 3 – 13.4 g/dL – 38.9 % K ( Seg 80.7% ) PT(INR) 1.19 aPTT 41.2/34 Chemistry ) TB/DB 11.39/ 6.43 mg/dL Na/K/Cl 137/3.9/104 mmol/L T-chol/Glu 93/ 116 mg/dL Ca/P/Mg 8.8/ 3.4/ 2.3 mg/dL AST/ALT 25/ 28 U/L LD/CK 387/ 82 U/L ALP/GGT 92/ 102 U/L BUN/Cr 13/ 0.7 mg/dL Prot/Alb 6.8/ 3.4 g/dL CRP 4.6 mg/dL UA ) RBC 0-1 WBC 2-4 Bilirubin 3+ Urobilinogen 4.0 Laboratory Finding

Chest PA ( )

EKG ( )

Problem list #1. Jaundice (Hyperbilirubinemia) #2. abdominal discomfort #3. pleural effusion, both

Initial assesment #1. 2 Viral hepatitis r/o drug-induced hepatitis r/o drug-induced hepatitis #3. pleural effusion, both Diagnostic plan #1.2 - viral marker, tumor marker - abdominal sono or abdominal CT - LFT f/u #3. - Chest x-ray (lateral decubitus) - Chest x-ray (lateral decubitus)

Clinical course

Viral marker Viral marker HBsAgnon-reactive anti-HBc IgGreactive anti-HBs AbPos(184.7) anti-HAV lgM non-reactive anti-HIVNegative Anti-HCVNegative Tumor marker Tumor marker AFP2.42 ( <4.0 ng/mL ) CEA1.92 ( <4.1 ng/mL ) CA 19-9< 2.00 ( <37 U/mL )

Abdominal CT ( )

CT ( ) Abdominal CT ( )

Echocardiography (8.23)

RV LV Flattening of LV posteror wall during diastole

% change = (E Expi - E Insp ) / E Insp x 100 = ( ) / 0.5 x 100 = 40% Mitral inflow Echocardiography (8.23)

Mitral septal annulus velocity

Echocardiography (8.23) Dilated IVC

Echocardiography (8.23) Hepatic vein

Cardiac angio 3D CT ( )

Hemodynamic evaluation

CAG ( )

OP FINIDING ( ) Op. name : pericardiectomy Biopsy : severe collagenous fibrosis with focal fibrin deposit

Chest PA

Bilirubin level f/u

Final diagnosis → Constrictive pericarditis