1. Left chest pain을 주소로 온 69세 여자환자
MGR
Left chest pain을 주소로 온 69세 여자환자
R1 정수웅 / prof. 정재헌

2. Chief Complaint Present Illness
박ㅇ하 F/69 Admission on
Chief Complaint
Left chest pain onset) 1주일전
Present Illness
69/F, HTN, old CVA, stable angina로 외부병원에서 po medication 하고 있는 자로 1주일 전부터 시작된 주로 들이 쉴 때 악화되는 left chest pain으로 본원 외래 방문함.
Her-2
98년 high dose chemotherapy : cyclophosphamide2300mg, etoposide 470mg, carboplatin 300mg
Bone suppression 빨리 시행하기 위해

3. Past medical history
DM/HTN/Tb/Hep (-/+/-/-)
Stable angina (+)
Previous stroke history (+)
3 years ago, but no residual sequelae
Past surgical history
PLIF d/t HIVD, 2010
Personal history
Smoking (+) 3 PY as ex-smoker
Alcohol (-)
Medication : candesartan, carvedilol, felodipine
acetyl L-carnitine, rebamipide

4. Review of system I
General fatigue (+) febrile sense (-) edema(-) weight loss(-) Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) sore throat (-) rhinorrhea (-) Eye & ENT visual disturbance (-) tinnitus (-) nasal obstruction(-) Respiratory cough (-) sputum (-) dyspnea (+) pleuritic chest pain (+) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5. Review of system II Gastrointestinal
A/N/V/D/C (-/-/-/-/-) hematemesis (-)
melena (-) hematochezia (-)
Urinary
dysuria (-) frequency (-) urgency (-) residual urine sense (-)
flank pain (-) nocturia(-) polyuria (-)
Musculoskeletal
pain (-) back ache (-) swelling (-) weakness (-)
Neurologic
syncope (-) seizure (-) dizziness (-) numbness(-)

6. Physical examination I
Vital sign /80 – 90회/min – 15회/min – 36.5°c
weight : 69kg height : 156cm BMI : 28.3 kg/m2
General alert & oriented
chronic ill looking appearance
Skin no rash no pigmentation
Head & Neck no neck vein engorgement
Eye & ENT isocoric pupil with PLR (++/++)
whitish sclera pinkish conjunctiva
PI (-) PTH (-/-)

7. Physical examination II
Chest clear breathing sound with crackle on the left side regular heart beat without murmur Breast symmetric breast no palpable mass Abdomen soft and flat abdomen normoactive bowel sound no tenderness / no rebound tenderness no palpable mass no abdominal bruit no hepatosplenomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-) Neurologic sensory change (-) motor change (-)

8. Initial lab finding CBC/DC 4360/mm² -11.8g/dl –36.5% -124K (seg 63.8%)
aPTT PT (INR) (1.04)
Chemistry
AST/ALT 24/32 IU/L BUN/Cr /0.5 mg/dL
ALP/GGT 58/48 IU/L Na/K/Cl /3.2/101 mmol/L
TB mg/dL Ca/P/Mg /2.7/1.9 mg/dL
Prot/Alb /3.2 g/dL Uric acid mg/dL
LD/CK /25 U/L CRP mg/dL
U/A
RBC 5~9/HPF WBC 5~9/HPF

9. Chest X-ray

10. EKG

11. Problem list
#1. solitary pulmonary nodule, about 2cm sized in RUL #2. left pleural effusion

12. Initial assessment and plan

13. Initial assessment and plan
#1. r/o primary lung cancer #2. r/o pneumonia with parapneumonic effusion #3. r/o pulmonary thromboembolism with pulmonary infarction #4. r/o tuberculosis

14. Diagnostic plan
D-dimer, tumor marker
Chest CT
PCNA if needed

15. D-dimer ( ~ 0.5 ug/mL)
CEA ng/mL ( ~4.1 ng/mL)
CA U/mL ( ~37 U/mL)

16. Chest CT

19. CT guided PCNA

21. Further workup
PET-CT
Brain MR
EGFR mutation analysis

23. Brain MR

25. STAGING

30. EGFR mutation analysis

31. Final diagnosis
#1. NSCLC (adenocarcinoma, T1N2M1b stage IV) with EGFR missense mutation in exon 18 #2. Pulmonary thromboembolism with pulmonary infarction

32. Therapeutic plan
#1. NSCLC (adenocarcinoma, T1N2M1b stage IV) with EGFR mutation + Gamma knife surgery for brain metastatic lesions Chemotherapy as follows Gemcitabine 1000mg/M IV on D1,8,15, q4wks #2. Pulmonary thromboembolism anticoagulation treatment (enoxaparin followed by warfarin)

33. Clinical course

34. Stable disease warfarin administration 12.8.3 12.8.8 12.9.5
Chest CT
Chest CT
Stable disease
warfarin administration
Diagnosed with EGFR + NSCLC
Chest CT f/u
Gemzar # Gemzar #2

35. Gemzar #1 Gemzar #2 Gemzar #3
Brain MR
Brain MR
Brain MR f/u
Diagnosed with EGFR + NSCLC
Gemzar # Gemzar #2 Gemzar #3

36. Increased Rt. Pleural effusion
Worsening dyspnea
Increased Rt. Pleural effusion
Diagnosed with EGFR + NSCLC SD
Gemzar #1 Gemzar #2 Gemzar #3 Gemzar #4 Gemzar #5

37. Gemzar #1 Gemzar #2 Gemzar #3 Gemzar #4 Gemzar #5CT CT
Chest CT f/u
Diagnosed with NSCLC SD
Gemzar # Gemzar #2 Gemzar #3 Gemzar # Gemzar #5

38. What is the best treatmentCT CT
Progressive Disease
What is the best treatment
at this point ?
Diagnosed with EGFR + NSCLC SD
Gemzar # Gemzar #2 Gemzar #3 Gemzar # Gemzar #5

39. Iressa (gefitinib) 250mg daily

40. CT CT PD
Diagnosed with NSCLC SD
Gemzar #1 ~ #5
Iressa 250mg daily

41. Brain MR
Brain MR
Partial remission
Diagnosed with EGFR + NSCLC
Gemzar #1 ~ #5
Iressa 250mg daily

42. Chest CT

43. CT CT
Stable disease PD PR
Diagnosed with NSCLC SD
Gemzar #1 ~ #5
Iressa 250mg daily

44. Clinical course Worsening dyspnea Increased Rt. Pleural effusionPD PR
Diagnosed with NSCLC SD
Gemzar #1 ~ #5
Iressa 250mg daily
anticoagulation as warfarin SD
Iressa 250mg daily
anticoagulation as warfarin