1. GI-GS-RAD.-PATH. conference 06-10-09
경희의료원 내과

2. 윤○병 (M/72) Adm
Case 1.
(C.C) Epigastric discomfort o/s) 내원 약 3달 전
(P.I) M/38. 평소 특이병력 없이 건강하게 지내던 환자로 내
원 약 3개월 전부터 epigastric discomfort 있어 06-7
-14 local에서 시행한 건강검진 (AP sono) 상 cecum
에 submucosal tumor 소견 보여 본원 IM
(Prof. 김효종) visit, abd. CT 및 colon double-contrast
barium study, small bowel study 시행 결과 ileal
cystic dilatation 발견되어 r/o intestinal duplication
impression 하 Op.위해 본원 GS (Prof. 이길연)
adm.

3. (Past Medical History)
HTN (-) DM(-) Hepatitis(-) Pulm. Tb. (-)
Op. Hx(+) : ’02 HIVD repair Op. (Discectomy)
’03 Herniorrhapy, Rt.
(Family History)
Unremarkable

4. Review of System
General Fatigue(-) Febrile sensation(-) Chill(-) Wt. Loss (-)
Skin Rash(-) Pigmentation(-)
H&N Headache(-) Sore throat(-)
Respiratory Cough(-) Sputum(-) Dyspnea(-)
Cardiac Chest pain(-) Orthopnea(-) Palpitation(-)
G-I A/N/V/D/C (-/-/-/-/-) Abd. discomfort(+) : Epigastric
Renal Dysuria(-) Urgency(-) Frequency (-) Hematuria(-)
B/Ext Upper back pain(-) Lower back pain (-)

5. Physical Examination (V/S) 120/80mmHg – 96/min – 20/min - 36.3°C (G/A)
Alert consciousness
Not so Ill-looking appearance
(Head & Neck)
No cervical LN enlargement
No neck vein engorgement
No thyroid enlargement
(E & ENT)
Isocoric pupil with PLR(++/++)
Pinkish conjunctiva with Clear sclera

6. Physical Examination (Chest)
Clear breathing sound without rale or wheezing
Regular heart beat without murmur
(Abdomen)
Soft & flat abdomen
Normoactive bowel sound Tenderness(-)
Rebound tenderness(-) Shifting dullness(-)
Hepatosplenomegaly (-)
(Back & Ext.)
CVA tenderness (-/-) Pretibial pitting edema(-/-)

7. Initial lab. findings (CBC/DC) (Chemistry) (U/A)
23800/mm3 – 13.8g/dL – 41.8% - 324K/mm3
(aPTT : 33.0 C PT : 13.4 C INR 1.01)
(Chemistry)
TB/DB / 0.26 mg/dL
Prot./Alb. 6.6 / 3.7 g/dL
AST/ALT 35/ 30 U/L
ALP U/L
BUN/Cr / 0.7mg/dL
Na/K/Cl / 3.8 / 105 mmol/L
T-Chol mg/dL
(U/A)
RBC 0-1 / WBC 0-1

8. Evaluations <Abd. CT> : 06-8-16 <Colon study> : 06-8-18
<Small bowel study> :
<Op.> :  Laparoscopic small bowel segmental
resection & Adhesiolysis distal ileum

9. Intestinal duplication (True diverticulum, ileum)
Diagnosis
Intestinal duplication
(True diverticulum, ileum)