1. MGR Department of Pulmonology 2007. 2.27 Prof. 박명재 /R1 조용덕

2. ID number; 11886946 M/42 오 0 환 2007.2.13 입원 C.C Rt. Lower chest pain o/s 내원 하루전 dyspnea P.I M/42, 특이 병력없던 없던 자로 내원 하루전 밤 10 시경에 Rt. Lower chest 에 뜨끔거리는 느낌과 함께 inspiration 시 pain 동반되었고 금일에는 pain 양상이 심해지 면서 dyspnea 발생하여 응급실 통하여 입원함 Present Illness (1)

3. PMHx.: HTN (-) DM (-) TB (-), viral Hepatitis (-) Op. Hx (-) drug Hx(-) FHx. : Unremarkable PHx. : Alcohol (-) Smoking (-) Present Illness (2)

4. GeneralFever(-) Chill(-) Fatigue(-) Wt loss(-) H & ENTheadache(-) Sore throat(-) Neck stiffness(-) RespiratoryCough(+) Sputum (+) dyspnea(+) Pleuritic chest pain (+): 특히 inspiration 시 CardiacChest discomfort(-) Orthopnea(-)Palpitation(-) GIAnorexia(-) Nausea(-) Vomiting(-) melena(-) Diarrhea(-) Constipation(-) Abdominal pain(-) GUFrequency(-) Urgency(-) Dysuria(-) Review of systems

5. V/S : 120/80mmHg –96/min– 20/min – 36.2°C G/A : Alert mentalityacute ill-looking appearance Skin : Rash (-) Pigmentation (-) H/N : No neck vein engorgement No palpable neck mass E/E/N/T : Isocoric pupil with PLR (++/++) PI(-) PTH(-/-) Chest : Regular heart beat without murmur symmetric expansion decreased breathing sound at RLLF without crackle dullness to percussion AbdomenSoft and obese Normoactive bowel sound No palpable abdominal mass No abdominal tenderness / rebound tenderness Back & ext. No CVA tenderness Pretibial pitting edema (-/-) Physical examination

6. CBC / DC 15770/mm 3 – 13.7g/dL – 39.2% - 309,000/mm 3 (Seg. 87.4%) INR /aPTT 1.14 / 33.9c 34 Blood chemistry Total bil./Direct bil. 1.36/0.19 mg/dL ALP /rGT 53/41 IU/L Protein/Albumin 7.0/3.9 g/dL AST/ALT 17/20 IU/L LDH/CK 422/81 IU/L BUN/Creatinine 18/1.4 mg/dL Na/K/Cl 138/4.1/103 mmol/L CRP 15.6 mg/dL U/A : RBC 0~1/HPF, WBC 0~1/HPF Initial lab. data

7. E K G

8. Initial Chest X-ray

9. Chest CT

10. #1 pleuritic chest pain #2 dyspnea Initial problem

11. Initial Access & Plan # pneumonia with pleural effusion D.P) sputum study, Blood culture, Urine culture ABGA F/U CBC/DC, CRP,ESR F/U chest PA Diagnostic thoracentesis T.P) O2 supply Antibiotics

12. # S) fever(-) pleuritic chest pain(+) o) sono –guided thoracentesis 시행함 pleural fluid analysis color : yellowish, pus like L.D.H : 2,823 U/L, protein : 5,6 g/dL, glucose: 218mg/dL WBC : 160,000/mm3 ( seg: neutrophils 92% ) pH :7.0 ADA :50IU/L chemistry L.D.H.: 422 U/L protein : 7.0 g/dL A) pneumonia with empyema P) chest tube inserton ceftriaxone 2g qd+ clindamycin 600mg q 8hrs F/U CXR, CBC/DC, CRP Clinical course HD#1

13. # S) fever(-)-> (+) : 39.2, pleuritic chest pain (-) O) Chest tube insertion 시행 -> 330ml drain 됨 A) pneumonia with empyema P) F/U CXR, CBC/DC, CRP urokinase infusion if needed Clinical course HD#2

14. S) fever (+) : 38.8, chilling (-), dyspnea (-), C/S (-/-) O) CRP: 27.Omg/dL WBC : 13,400 /ul chest tube : 330 ml drainage A) pneumonia with empyema P) urokinase infusion-> drainage antibiotic change (piperacillin/tazobactam 4.5g q 8hrs) Clinical course HD#3

15. # S) fever (+): 38, chilling (-) pleuritic pain(-) O) WBC 10760/mm 3 CRP 19.0 urokinase infusion : 330 -> 80 -> 60 A) pneumonia with empyema P) antibiotic change ( levofloxacin 750mg qd) Clinical course HD#6

16. # s) fever (-) o) F/U chest CT p) chest tube reinsertion Clinical course HD# 9

17. # S) fever(-) pleuritic chest pain (-) O) chest tube reinsertion 시행함 -> 30 ml drainage 됨 A) pneumonia with empyema p) urokinase infusion 고려 Clinical course HD# 10

18. # S) fever(-) pleuritic chest pain (-) o) chest tube; 30ml urokinase infusion : bloody 20ml A) pneumonia with empyema P) F/U CXR Clinical course HD# 11

19. # S) fever (-) chills(-) C/S (-/-) pleuritic chest pain(-) O) WBC 7850/ ul (seg: 60.8%) CRP: 0.7 mg/dL chest tube drainage 30 ->20 -> 0 -> 0 A) pneumonia with empyema P) chest tube remove 고려 Clinical course HD# 14

20. Clincal course Ceftriaxone Clindamycin Tazocin Levofloxacin Chest tube insertion 2/18 2/152/132/222/26 2/14 Chest tube insertion

21. Pneumonia with empyema Final diagnosis