Department of Pulmonology R2 In Ah Choi Problem Cases Case 1 기침을 주소로 내원한 60대 여성 Case 2 우측 흉통을 주소로 내원한 18세 여성 Case 3 기침과 가래를 주소로 내원한 50대 남성 Department of Pulmonology R2 In Ah Choi

Case 1 기침을 주소로 내원한 60대 여성 Chief complaint Present illness 11889216 Adm 07-2-28 Chief complaint known pleural effusion, Lt O/S) 내원 2개월 전 Present illness 특이 병력 없던 63세 여성으로 약 2달 전 fever를 동반한 cough 발생하여 인근 병원 방문함. 그곳에서 폐에 물이 찼다는 말 들었으며 항생제 사용 후 증상은 호전되었으나 항생제에 반응 없고 흉수 배액 후에도 재발하자 malignant effusion 배제하기 위해 VATS biopsy 시행 권유받고, 흉부외과 있는 큰 병원에서 조직검사 위해 본원 방문함 * 외부병원 입원기간: 성가병원 2006.12.31~ 2007.2.8 chest CT, bronchoscopy-no endobronchial lesion thoracentesis 3차례 , pleural biopsy 시행

Review of System General fatigue (-) febrile sense (-) chilling (-) myalgia (-) weight loss(+) : 2kg/ 2wks night sweating (-) Skin rash (-) itching (-) pigmentation (-) Respiratory cough (+) sputum (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-) Gastrointestinal swallowing (-) jaundice (-) abdominal pain (-) A/N/V/D/C (+/+/-/-/-)

Physical Examination Vital sign 120/80mmHg – 80/min- 20/min- 36.5’C General alert mentality acutely ill looking appearance Head & Neck cervical LN enlargement (-) Thorax symmetrical chest expansion decreased breathing sounds at RLLF decreased vocal fremitus at RLLF coarse breathing sounds at both lung field regular heart beat without murmur Abdomen soft & flat abdomen normoactive bowel sound tenderness (-) rebound tenderness (-)

Initial lab finding CBC/DC 4510/mm² -14.9 g/dl – 42.4 %- 262K (seg : 77.8%) aPTT 39.5/34 sec PT(INR) 13.3S100C13.3 (1.00 ) Chemistry TB/DB 0.52/0.08 mg/dL AST/ALT 29/23 U/L ALP/GGT 81/25 U/L protein/alb 6.2/3.1 g/dL LD/CK 465/54 U/L BUN/Cr 13/0.6 mg/dL Na/K/Cl 134/3.9/95 mmol/L CRP 5.7mg/dL UA RBC 0-1/HPF WBC 0-1/HPF

Chest X ray

Chest X ray

Chest CT (2/17-외부)

Chest CT (2/17-외부)

Impression Initial Plan 1. Tb pleurisy with pulmonary tuberculosis r/o malignancy Initial Plan 1. chest CT review 2. Thoracentesis 3. Tb culture, AFB stain, MTB PCR 4. quantiFERON-gold

Pleural fluid analysis (2/28) RBC 17920 WBC 6400 neutrophils 95% Glucose 145 Protein 4400 (6.2) Albumin (3.1) ADA 133 PH 7.4 AFB stain (-) AFB stain culture (-) MTB PCR (-) Sputum (2/28) MTB PCR (-) AFB stain (-) MTB culture/AFB stain (-)

Clinical course Tb medication (HERZ) 2/28 3/4 3/15 3/20 QFT–gold(3/5) positive (3/8) Tb medication (HERZ) 2/28 3/4 3/15 3/20

F/U Chest X ray (3/19)

Case 2 우측 흉통을 주소로 내원한 18세 여성 Chief complaint Present illness Rt chest wall pain O/S) 내원 1개월 전 Present illness 특이 병력 없던 18세 여성으로 2년 전부터 무리하게 일한 후 간간히 발생하는 chest wall pain 있었으나 그냥 지내다 06.10월부터 pain 악화되고 deep breathing 시마다 발생, 2007년 1월local 의원에서 chest CT 촬영 후 Tb 의심되어 07.1.16부터 보건소에서 Tb medication 시작함. 약물 복용 후 2주간 증상은 호전되었으나 2주 후부터 다시 상기 증상 동반되어 큰 병원 권유 받고 내원 11886812 신0영 F/18 Adm 07-2-13 Past medical history DM/HTN/Tb/hepatitis (-/-/-/-) OP Hx(-) Personal history Smoking ( + ) : 1달 전 금연. 2 PY Alcohol ( +) : 1회/1~2개월

Review of System Physical Examination General fatigue (-) febrile sense (-) chilling (-) myalgia (-) weight loss(+) night sweating (+) Respiratory cough (+) sputum (+) tachypnea (-) DOE(+): MRC II Cardiac chest pain (-) palpitation (-) orthopnea (-) Physical Examination Vital sign 120/80-80-24-36.5’C General alert mentality acutely ill looking appearance Thorax localized wheezing at RLLF regular heart beat withour murmur

Initial lab finding CBC/DC 4070/mm² -11.1 g/dl – 34.4 %- 297K (seg : 59.1%) aPTT 32.9/34 sec PT(INR) 13.6s96c13.3 (1.03) Chemistry TB/DB 0.33/0.12 mg/dL AST/ALT 24/9 U/L LD/CK 580/79 U/L BUN/Cr 3/0.5 mg/dL protein/alb 7.4/3.2 g/dL Na/K/Cl 143/4.1/102 mmol/L UA RBC 0-1/HPF WBC 0-1/HPF

Chest X ray