GS – GI – RAD - PATH Conference 외 과 배영식
Case I C.C) RUQ pain o/s) 한달전 박 O 순 M/74 C.C) RUQ pain o/s) 한달전 P.I) M/74 11월 초 abrup한 RUQ pain 발생하여 응급실 방문하여 GB stones 진단받고 소화기내과 F/U 하던중 증세 severe 해져 06. 11. 29 응급실 재방문 후 소화기 내과로 입원함.이후 수술 위하여 외과로 전과됨. PMHx) DM/HTN/hepatitis/TB (-/+/-/-) OpHx) (-) PHx) alcohol (-) smoking (-)
Review of Systems 1.General Fever(+): 37.7℃ Chill(+) Fatigue(-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)
Review of Systems 5. Abdomen A/N/V/D/C(+/-/-/-/-) Abdominal Pain(+): RUQ & epigastric Abdominal Discomfort(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Bowel Habit Change(-)
Physical Examination 1.General Alert Mentality, acute ill-looking appearance 2.E/ENT Isocoric Pupil with PLR(++/++) no yellowish sclera Pinkish Conjunctiva 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale
5. Abdomen Physical examination Soft & flat Abdomen Hypoactive Bowel Sounds Tenderness(+) : RUQ Rebound tenderness(-) Murphy’s sign(+) Muscle Guarding(-) CVA Td(-/-)
Lab findings CBC 14000 – 13.3 – 39.4 – 240K (seg.86.8%) CRP 7.2 Na/K/Cl 125/3.1/94 BUN/Cr 14/1.2 TB/DB 1.19/0.19 AST/ALT 27/26 ALP /rGT 69/249 Amylase / Lipase 77 /8 U/A RBC 0-1 WBC 0-1
Work up Abdominal US ( 06. 11. 9 – ER) Abdominal US ( 06. 11. 24) Liver CT (06. 11. 30) EUS (06. 12. 1)
Impression Acute cholecystitis with GB stones
Laparoscopic cholecystectomy Operation (06-12-4) Laparoscopic cholecystectomy
Case II C.C) Fever o/s) 한달전 김 O 원 M/61 C.C) Fever o/s) 한달전 P.I) M/61,한달전 fever(38.8℃), chill, vomitig, watery diarrhea 증세보여 응급실 경유 감염내과로 입원함. 이후 시행한 abdominal US에서 GB perforation 소견보여 소화기내과로 전과후 PTGBD insertion 시행함. 이후 수술 위하여 외과 입원함, PMHx) DM/HTN/hepatitis/TB (-/-/-/-) OpHx) (-) PHx) alcohol (-) smoking (-)
Review of Systems 1.General Fever(+): 38.8℃ Chill(+) Fatigue(-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)
Review of Systems 5. Abdomen A/N/V/D/C(+/+/+/+/-) Abdominal Pain(+): RUQ & epigastric Abdominal Discomfort(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Bowel Habit Change(-)
Physical Examination 1.General Alert Mentality, acute ill-looking appearance 2.E/ENT Isocoric Pupil with PLR(++/++) no yellowish sclera Pinkish Conjunctiva 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale
5. Abdomen Physical examination Soft & flat Abdomen Hypoactive Bowel Sounds Tenderness(+) : RUQ Rebound tenderness(-) Murphy’s sign(-) Muscle Guarding(-) CVA Td(-/-) PTGBD inserted state
Lab findings CBC 6800 – 13.5 – 37.7 – 106K (seg.89.2%) CRP 27.9 Na/K/Cl 138/3.6/104 BUN/Cr 24/1.5 TB/DB 2.41/1.14 AST/ALT 127/88 ALP /rGT 197/108 Amylase / Lipase 28/25 U/A RBC 0-1 WBC 0-1
Work up Abdominal US ( 06. 11. 3 ) Abdominopelvic CT ( 06. 11. 3) PTGBD insertion (06. 11. 3) Gastroscope (06. 11. 4) PTGBD tubogram ( 06. 11. 9 / 11. 16)
with GB stones, perforated Impression Acute cholecystitis with GB stones, perforated
Laparoscopic cholecystectomy Operation (06-12-5) Laparoscopic cholecystectomy