김 O 익 (M/82) C.C. > Anorexia o/s) 내원 약 4 주전 P. I. > 1 년 간 7kg 의 weight loss 있었고, 두 달 전 시행한 abd CT 및 위내시경에서 양성종양 발견되어 observation 하던 중, 최 근 한 달 전부터 anorexia 있고 한 달 사이 1kg 의 weight loss 있어 보훈병원 방문, 위내시경 재시행하여 huge SMT 발견, r/o malignant GIST imp 으로 수술 위해 입원함. PMHx.> HTN/DM/Tbc/Hepatitis (+/-/-/-) old CVA Hx(+) BPH(+) Operation (+): 25 년전 SDH 로 brain op. ( 국립의료원 )

Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (+): 1 년간 7kg, 한 달간 1kg 감소 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

Review of Systems 5. Abdomen A/N/V/D/C(+/-/-/-/-) Abd pain(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-)

Physical Examination 1.General Alert Mentality Chronic ill appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

Physical Examination 5. Abdomen Soft & Flat Abdomen Normoactive Bowel Sounds Abd Td/rTd (-/-) Muscle Guarding (-) CVA Td (-/-) Organomegaly (-)

Initial Lab. finding CBC 5780 – 11.7 – 34.4 – 289K (seg %) Pro/Alb 6.3 / 3.7 TB/DB 1.01/0.36 AST/ALT 22/14 ALP / GGT 76/7 BUN/Cr 11/1.1 Na/K/Cl 135/4.6/98

Work up 외부 Abd CT ( ) Stomach CT ( ) PET CT ( ) 외부 Gastroscopy ( ) Gastroscopy. ( ) S S S P

Impression Large cell neuroendocrine carcinoma

Operation Total gastrectomy  Final path. Dx.: Large cell neuroendocrine carcinoma

김 O 선 (F/71) C.C > Abdominal pain o/s) 1 주일 전 P. I > 특이병력 없는 자, 내원 7 일전 local 병원 ( 백병원 ) 방문하여 시행한 복부 초음파에서 GB stone 진단 받고 수일간 항생제 치료 받다 증상 호전 안 되어 동부 제일병원 방문하여 A-P CT 촬영 후 GB perforation 의심, 큰 병원 권유 받고 본원 ED 통 해 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/+/-/-) OPHx > (+) 86' open appendectomy (at 위생병원 )

Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

Review of Systems 5. Abdomen A/N/V/D/C(-/-/-/-/-) Abd pain(+): epigastric, RUQ Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Anal discharge(-)

Physical Examination 1.General Alert Mentality Acute-ill looking appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) Palpable neck mass (-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

Physical Examination 5. Abdomen Soft Abdomen Normoactive Bowel Sounds Abd Td/RTd (+/+): RUQ, epigastric CVA Td (-/-) Organomegaly (-)

Initial Lab. finding CBC – 12.1 – 34.5 – 297K (seg. 82.7%) Pro/Alb 5.8 /3.2 TB 0.69/0.35 AST/ALT 28/29 ALP/GGT 127 /69 BUN/Cr 9/0.5 Na/K/Cl 134/4.6/97 CRP 19.53

Work up 외부 Abd CT PTGBD insertion Tubogram ( ) Tubogram ( ) GB & billiary CT ( ) E.R.C.P. ( ) S

Impression Acute cholecystitis c GB perforation

Operation Lap. cholecystectomy & drainage

이 O 매 (F/71) C.C > Abdominal discomport o/s) 2 주 전 P. I > 상기 69 세 여자환자, 특이병력 없던 자로 2 주전부터 abdominal discomport 있어 본원 IG 외래 통하여 colonoscopy 및 biopsy 시행하였으며 hepatic flexure ca. obstruction.imp. 으로 외래 통하여 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/-/-/-) Operation> (+):08'both TKR

Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

Review of Systems 5. Abdomen A/N/V/D/C(+/-/-/-/-) Abd pain(+): epigastric, periumbilical Abd discomfort(+) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Anal discharge(-)

Physical Examination 1.General Alert Mentality Chronic-ill looking appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

Physical Examination 5. Abdomen Soft Abdomen Normoactive Bowel Sounds Abd Td/RTd (+/-): periumbilical CVA Td (-/-) Organomegaly (-)

Initial Lab. finding CBC – 10.6 – 32.0 – 425K (seg. 80.4%) Pro/Alb 7.7 /4.2 TB 0.51/0.16 AST/ALT 19/8 ALP/GGT 61 /15 BUN/Cr 9/0.6 Na/K/Cl 135/3.5/99 CA 19-9/CEA/AFP /4.04/1.66

Work up Small bowel CT Chest CT Neck CT Breast US PET CT Colonoscopy S F S S

Impression Hepatic flexure cancer c duodenum invasion  Final path. Dx: Hepatic flexure ca. c ca. peritonei

Operation Rt hemicolectomy c duodenum wedge resection

Lymph node in the Lt. supraclavicular fossa (the area above the left clavicle) The finding of an enlarged, hard node has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels. Virchow’s Node

its supply from lymph vessels in the abdominal cavity. on the left side of the neck where the lymphatic drainage of most of the body (from the thracic duct) enters the venous circulation via the left subclavian vein. The metastasis blocks the thoracic duct leading to regurgitation into the surrounding nodes (ie. virchow's node. ) Another concept is that one of the supraclavicular nodes corresponds to the end node along the thoracic duct and hence the enlargement Virchow’s Node