Chief Complaint RUQ pain onset > remote: 3 개월 전 recent: 내원당일 오전 8 시 Present Illness M/ 68, 특이병력 없던 자 3 개원 전부터 intermittent RUQ pain 시작되어 2 주 전부터 local 병원에서 소화제, 위염약 복용하였으나 증상 호전 없었고, 내원 당일 아침 식사 후 통증 악화되어 응급실 통해 입원함. * 1997 ureter stone 으로 URO 입원 시 GB stone 으로 op 권유, 무증상으로 refuse Case 4 천 O 돈 (M/68) Admission date :
Past-medical history DM / HTN / Tbc / Hepatitis (-/-/-/-) Operation Hx (+) : 2002 – inguinal hernia Rt. Op. Medication Hx (-) Family history None Personal history S S moking (+): 30 갑년 (1 갑 X 30 년 ) A lcohol (+): social
Review of system Fever(-) Chilling(-) Wt loss: 3kg/2mo Abdominal pain(+) A/N/V/D/C(-/-/-/-/-) Melena(-)Hematochezia(-)Hematemesis(-) Flank pain(-)dysuria(-) Physical examination V/S: 120/80 mmHg – 72/min – 20/min – 36.5 ’C Alert mentalityAcute-ill looking Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen Td / rTd / MG (+ / - / - ) : RUQ Td Murphy’s sign(+)CVA Td(-/-)
Initial Lab Findings CBC/DC 10,750 /mm 3 (73.3 %) – 14.7 g/dL – 44.7 % - 357,000 /mm 3 PT(INR) 13.0 sec (0.98)aPTT 35.1 sec Chemistry TB/DB 1.50/1.03 mg/dL Prot/Alb 7.6/4.2 g/dL AST/ALT 163/162 U/LBUN/Cr 10/0.6 mg/dL ALP/GGT 567/997 U/LNa/K/Cl 138/4.6/100 mmol/L LD/CK 527/61 U/LCa/P/Mg 8.5/3.3/2.1 mg/dL CRP 1.98 CA 19-9/CEA /3.67
Work Up Liver CT Liver-GB-Pancreas sono MRCP ERCP with EST, EPBD, ENBD Tubogram
Frozen biopsy (S ) Diagnosis : Liver, right, lobectomy: Biliary intraductal papillary neoplasm with low-grade dysplasia Gallbladder, cholecystectomy: Chronic cholecystitis Cholelithiasis
GS op ( ) Rt hepatic lobectomy
Final Diagnosis Biliary intraductal papillary neoplasm with low-grade dysplasia