Case Presentation

Case Presentation 성균관대학교 의과대학 2007313075 손의영

Chief Complain • 김O식, M/83 • Dyspnea • Onset : 2 weeks ago

Present Illness • 2011.02 TB pleurisy로 치료 받은 후에 간헐적으로 dyspnea호소 • 2000.03.09 Pneumonia w/ respiratory failure로 입원 후 치료받고 퇴원 • 2009. 우울증 진단 후 1년간 medication 복용 • 이후 1년에 약 1차례 씩 감기로 인한 dyspnea로 입원 치료 함

Present Illness • 2011.04.05 cough, yellowish sputum 증가dyspnea aggravation  충주의료원 방문 Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원 • 2011.04.06 Foley catheter insertion • 2011.04.07 insomnia, hallucination 및 말이 많아지는 양상 보임 • 2011.04.09 스스로 line remove 하려고 하며 irritability 발생 ABGA 7.388 – 65.1 – 65.2 – 38.4 SpO2 91.7% CO2 retention aggravation 되어 보호자가 원하여 본원 내원

Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( + / + / - / - / - ) • 약물력 • Drugs for Depression (During 1 hour) • 2011.04.05. : ciprofloxacin, Tazobactam, Erythromycin • 2011.04.10. : Tazobactam, Levofloxacin으로 항생제 변경 • 수술력 • 없음 • FHx. • 특이사항 없음 • SHx. • Smoking: ex-smoker 30PA (30yr x 1 pack)

Review of system • GW / EF ( + / + ) • Weight change ( - ) • Fever / chill ( - / - ) • Headache / dizziness ( - / - ) • Rhinorrhea / cough/ sputum ( - / + / + ) : yellowish • Dyspnea (+) : ATS grade III • chest pain / palpitation ( - / - ) • Anorexia / nausea / vomiting ( - / - / - ) • abdominal pain / discomfort ( - / - ) • Constipation / diarrhea ( - / - ) • Hematemesis / melena / hematochezia( - / - / - ) • Urinary Sx( - ) • Arthralgia( - ) • Myalgia( - )

Physical Exam • V/S 140/83mmHg - 108- 24- 36℃ • G/A Chronic ill-looking appearance • Mentality Alert & well orientation • HEENT not anemic conjunctivae, anictericsclerae Dehydrated tongue (-) PNS tenderness(-) PTH/PI (-/-) JVP (-) Neck VE (-) Cervical LNE (-/-) Thyroid enlagement (-) • Chest Symmetric chest expansion Iregularheart beat w/o murmur Clean breathing sound w/o wheezing

Physical Exam • Abdomen Soft & flat Bowel sound – normoactive No tenderness/rebound tenderness No shifting dullness • Back No CVAT • Extremities Skin rash(-) Clubbing (-) Joint ROM limitation (-) Joint swelling & stiffness (-) Joint deformity (-)

Spirometry / EKG

Imaging

Lab • WBC▲ 11.25 x10³/μL • Neut.▲ 92.2% (seg.) • Eo. 0.1% • RBC▼ 3.80 x10³/μL • Hb▼ 11.3 g/dL • Hct▼ 36.1% • PLT262,000/μL • Protein▼ 4.2 g/㎗ • Albumin▼ 2.7 g/㎗ • Globulin▼1.5 g/㎗ • AST35 U/l • ALT37 U/l • ALP 77 U/l • BUN 21 mg/dL • Cr 0.92 mg/dL • BUN/Cr 23.0 • CRP▲ 4.06 mg/dL • Na 140 mmol/ℓ • K▼3.4 mmol/ℓ • Cl▼ 96 mmol/ℓ

Problem List / Assessment • Problem List • #1. Dyspnea • #2. Depression • #3. Mania • #4. Aggravation of Coughand Sputum • #5. CO2 retention • #6. Leukocytosis • #7. increased CRP • Assessment • #1, 4, 5, 6, 7 : R/O Acute Exacerbation of COPD • #2, 3 : Bipolar disorder

AE of COPD – Etiology • Primary • Tracheobronchial infection • Air pollution • Secondary • Pneumonia • Pulmonary embolism • Pneumothorax • Rib fracture / Chest trauma • Inappropriate use of sedatives, narcotics, β-blocking agents • Right and/or Left heart failure or arrhythmias

AE of COPD –

Lung cancer – Px • Non-small lung cancer의 Stage에 따른 예후 • Stage IA : MSD 60개월 / 5YSR 50% • Stage IB : MSD 43개월 / 5YSR 43% • Stage IIA: MSD 34개월 / 5YSR 36% • Stage IIB: MSD 18개월 / 5YSR 25% • Stage IIIA: MSD 14개월 / 5YSR 19% • Stage IIIB: MSD 10개월 / 5YSR 7% • Stage IV : MSD 6개월 / 5YSR 2%

Case Presentation