Right chest pain 을 주소로 내원한 65 세 남자 호흡기내과 R2 한재준 MGR

C.C.: Right chest pain o/s ) 7 days ago C.C.: Right chest pain o/s ) 7 days ago P.I.: 특별한 medical history 없이 지내던 65 세 남자로 일주일 전부터 시작된 기침과 right chest pain ( 오른쪽 늑골부위에 국한된, 기침이나 호흡시 악화, 찌르는 듯 한 통증 ) 으로 개인병원 방문 후 큰 병원 권유받고 본 원 외래 통하여 입원. P.I.: 특별한 medical history 없이 지내던 65 세 남자로 일주일 전부터 시작된 기침과 right chest pain ( 오른쪽 늑골부위에 국한된, 기침이나 호흡시 악화, 찌르는 듯 한 통증 ) 으로 개인병원 방문 후 큰 병원 권유받고 본 원 외래 통하여 입원 정 0 섭 남 /65 adm.:

Past Medical Hx. Past Medical Hx. DM/ HTN/ Hepatitis/ pul. Tb: (- /- /- /- ) Operation history: None Drug medication Hx.: None Family History Family History 형 - 간디스토마로 치료 형 - 간디스토마로 치료 Personal History Personal History 고향 : 전라남도 곡성 ( 섬진강 유역 ) 고향 : 전라남도 곡성 ( 섬진강 유역 ) travel history : nonspecific travel history : nonspecific Smoking: none Smoking: none Alcohol: social drinking Alcohol: social drinking

Review of System General : weight loss(-) fatigue(-) fever (-) chill(-) malaise(-) sweating(-) General : weight loss(-) fatigue(-) fever (-) chill(-) malaise(-) sweating(-) H & N : headache(-) neck stiffness(-) H & N : headache(-) neck stiffness(-) Eye & ENT: rhinorrhea(-) sneezing(-) obstruction(-) sore throat(-) Eye & ENT: rhinorrhea(-) sneezing(-) obstruction(-) sore throat(-) Respiratory : cough(+) sputum(+): scanty amount, yellowish Respiratory : cough(+) sputum(+): scanty amount, yellowish dyspnea(-) hemoptysis(-) dyspnea(-) hemoptysis(-) Cardiac : chest pain(-) palpitation(-) orthopnea(-) Cardiac : chest pain(-) palpitation(-) orthopnea(-) paroxysmal nocturnal dypnea(-) paroxysmal nocturnal dypnea(-) GI : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) heartburn(-) GI : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) heartburn(-) Renal : dysuria (-),urgency(-), frequency(-) incontinence(-) Renal : dysuria (-),urgency(-), frequency(-) incontinence(-) Musculoskeletal :back pain(-) joint pain(-) Musculoskeletal :back pain(-) joint pain(-) Nervous : seizure(-) stroke(-) dizziness(-) Nervous : seizure(-) stroke(-) dizziness(-)

Physical examination Vital sign Vital sign 110/ 70 mmHg- 80 /min- 21 /min o C 110/ 70 mmHg- 80 /min- 21 /min o C General General Alert mental state Alert mental state Acutely ill looking appearance Acutely ill looking appearance Head & neck Head & neck  No neck vein engorgement  No cervical lymph node enlargement Eye & ENT Eye & ENT  Isocoric pupil with PLR(++/++)  Pinkish conjunctivae Clear sclerae  No pharyngeal injection PTH(-/-)

Physical examination Thorax: Thorax: Symmetric chest expansion Symmetric chest expansion Coarse breathing sound with crackle, RLLF Coarse breathing sound with crackle, RLLF Regular heart beat without murmur Regular heart beat without murmur Abdomen: Abdomen: Soft and flat abdomen Soft and flat abdomen Normoactive bowel sound Normoactive bowel sound No abdominal tenderness/rebound tenderness No abdominal tenderness/rebound tenderness No hepatosplenomegaly No hepatosplenomegaly Back & Extremities: Back & Extremities: CVA tenderness (-/-) CVA tenderness (-/-) Pretibial pitting edema(-/-) Pretibial pitting edema(-/-) Neurology Neurology Motor: intact Sense: intact Motor: intact Sense: intact

Initial lab findings CBC/DC CBC/DC  8070mm g/dL- 47.8%- 401K/mm 3 (seg: 68.4% eosin. : 4.7% eosin. count 379/μL ) Chemistry Chemistry  TB/ DB: 0.5/ 0.1 mg/dL Protein/ albumin: 6.4/ 3.0 g/dL  AST/ ALT: 47/ 47 U/L ALP: 94 U/L LD/ CK: 387/48  BUN/ Cr: 20/ 1.0 mg/dL Na/K/Cl: mmol/L  Ca/ P/ Mg :  CRP : 4.1mg/dL U/A RBC: 0~1 WBC: 0~1 protein: (-) U/A RBC: 0~1 WBC: 0~1 protein: (-)

EKG

Chest X-ray

Initial problem lists #1. Rt. chest pain #1. Rt. chest pain #2. Rt. Pleural effusion #2. Rt. Pleural effusion #3. Increased AST/ALT #3. Increased AST/ALT

Initial assessment and plans #1 & #2. A) Right pleural effusion parapneumonic, r/o tuberculosis, malignant effusion … parapneumonic, r/o tuberculosis, malignant effusion … P) Diagnosic thoracentesis ( LDH, Protein,Cell count &D/C, ADA, pH, cytology ) Sputum study (Gram stain & direct smear, aerobic bacteria culture, Fungus, AFB stain & TB culture) Sputum study (Gram stain & direct smear, aerobic bacteria culture, Fungus, AFB stain & TB culture) #2. Increased AST/ALT #2. Increased AST/ALT A) Hepatitis P) Viral markers (HBsAg, Anti-HBs, Anti-HBc, Anti-HAV, Anti-HCV. ) Abdominal ultrasonography Abdominal ultrasonography

Thoracentesis (HD1) Gross: Yellowish Gross: Yellowish Chemistry Chemistry LDH:293U s-LDH:387 (> 0.6) Protein:5100mg/dL s- Prot.: 6.4 (> 0.5) Glu:181mg/dL ADA:57 Differential count Differential count RBC: 80000/mm 3 WBC: 17600/mm 3 RBC: 80000/mm 3 WBC: 17600/mm 3 (neutrophil:12%, lymphocytes:6%, eosinophils:61%, monocytes 21%) pH: 7.5 pH: 7.5

수 개월 전 임진강에서 게장 먹은 적 있음 수 개월 전 임진강에서 게장 먹은 적 있음 P.w. skin test : 4x4/9x10 P.w. skin test : 4x4/9x10 C.s. skin test : 4x4/6x8 C.s. skin test : 4x4/6x8 Sputum ova study : ? Sputum ova study : ? stool ova study : negative stool ova study : negative Sputum AFB stain : negative Sputum AFB stain : negative Sputum study: no growth Sputum study: no growth

Chest CT

Clinical course

Viral markers(HD ) HBsAg (+) Anti-HBs (-) Anti-HBc (+) HBeAg (-) Anti-Hbe (+) HBV DNA hybridization : negative Anti-HAV IgM : non-reactive Anti-HCV : negative Anti-HIV : negative

Abdominal US(HD 7)

Final Diagnosis 1. Paragonimiasis 2. Chronic B viral hepatitis Management 1. Praziquantel 1 회 25mg/kg 용량으로 하루 3 회 2 일간 복용 2. LFT follow up