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

2. 11922635 고 O 현 (M/61) Visit OPD on 2007.8.22 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.

3. 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 ( - )

4. 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(-)

5. Physical Examination Bwt :72kg Ht:174.3cm BMI:23.7kg/m 2 V/S) 120/80-80-20-36.3 ℃ (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

6. 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

7. CBC/DC ) 7,700 /mm 3 – 13.4 g/dL – 38.9 % - 119 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

8. Chest PA (2007.8.22)

9. EKG (2007.8.22)

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

11. 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)

12. Clinical course

13. 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 )

14. Abdominal CT (2007.8.23)

15. CT (2007.8.23) Abdominal CT (2007.8.23)

16. Echocardiography (8.23)

18. RV LV Flattening of LV posteror wall during diastole

19. % change = (E Expi - E Insp ) / E Insp x 100 = (0.7-0.5) / 0.5 x 100 = 40% Mitral inflow Echocardiography (8.23)

20. Mitral septal annulus velocity

21. Echocardiography (8.23) Dilated IVC

22. Echocardiography (8.23) Hepatic vein

23. Cardiac angio 3D CT (2007.8.27)

24. Hemodynamic evaluation

26. CAG (2007.8.29)

27. OP FINIDING (07.9.11) Op. name : pericardiectomy Biopsy : severe collagenous fibrosis with focal fibrin deposit

28. 2007.8.222007.9.21 Chest PA

29. Bilirubin level f/u

30. Final diagnosis → Constrictive pericarditis