기침을 주소로 내원한 60 세 여자환자 호흡기내과 / R1 김민제

김 O 임 (F/60) Adm 주소 Cough onset time) 내원 1 달 전 현병력 60 세 여자환자. HTN, dyslipidemia 로 타 병원에서 medication 하며, GERD 와 gastritis 진단 하 본원 소화기내과 (Prof. 장재영 ) OPD F/U 중으로, 내원 한달 전부터 시작된 cough, sputum, rhinorrhea 증상에 대해 타 병원 medication 하였으나 증상 지속되어, 본원 소화기 내과 방문. Chest X-ray, Chest CT 시행 결과 r/o metastatic cancer, r/o miliary tuberculosis 소견 보여 further evaluation 위하여 호흡기 내과 의뢰된 후 외래 통하여 입원.

과거력 DM/HTN/TB/Hepatitis (-/+/-/-) HTN, dyslipidemia (+) : 삼성제일병원 GERD, gastritis (+) : 본원 소화기 내과 Op Hx (+) : 2010 년 Hysterectomy d/t Endometriosis, 약 10 년 전 Lt. pterygium op 개인력 Smoking (-) Alcohol (-) 가족력 (-)

약물 복용력 Losartan 50mg qd Hydrochlorothiazide 25mg qd Atorvastatin 10mg qd Levosulpiride 25mg bid Omeprazole 40mg qd

Review of system General fever(-) chills(-) body weight loss(-) Skin rash(-)itching(-)pigmentation(-) HEENT headache(-)sore throat(-)rhinorrhea(+) Respiratorycough(+)sputum(+)dyspnea(-) Cardiac chest pain(-)palpitation(-)syncope(-) GIA/N/V/D/C(-/-/-/-/-)abdominal pain(-) hematochezia(-)melena(-)hematemesis(-) GUflank pain(-)hematuria(-)dysuria(-) Musculoskeletal weakness(-)pain(-)numbness(-) Nerve system dizziness(-)sensory loss(-)motor weakness(-) Whitish Sputum (+) Hemoptysis(-) Dyspnea(-) Weight loss (-)

Physical examination Vital sign 130/80mmHg - 84/min - 18/min °C Height : 159.2cm Weight : 62.6 kg BMI : 24.7kg/m 2 General Alert mentality Not ill looking appearance HEENT Isocoric pupil c PLR (++/++) Cervical LN enlargement (-) PI(-)/PTH(-/-) Neck stiffness(-) Thorax Symmetrical chest expansion Clear breathing sound without rale Regular heart beat without murmur

Physical examination Abdomen Soft & flat abdomen Normoactive bowel sound Abdominal Td/rTd(-/-) Muscle guarding(-) Neurology Motor Sensory 100 ⅤⅤ ⅤⅤ

Initial Lab Findings CBC/DC 6,130/mm² g/dL – 39.5% - 321K (seg. 70.3%) PT(INR)13.0 sec (0.92) aPTT30.8 sec Chemistry Prot/Alb7.3/4.1 g/dL TB0.44 mg/dL AST/ALT16/15 IU/L GGT 13 IU/L BUN/Cr15/0.6 mg/dL Na/K/Cl142/3.7/104 mEq/L Ca/P/Mg9.3/3.7/2.1 mg/dL LD/CK349/62 U/L CRP<0.3 mg/dL

Chest X-ray

EKG

Initial problem list #1. Cough, sputum, rhinorrhea symptoms #2. Disseminated reticulonodular opacities of entire lungs #3. Known HTN #4. Known dyslipidemia #5. Known GERD #6. Known gastritis

Initial assessment & plan #1. Cough, sputum, rhinorrhea symptoms #2. Disseminated reticulonodular opacities of entire lungs A) R/o hematogenous lung metastasis, r/o tuberculosis, r/o sarcoidosis P) Chest/abdominal CT, PET CT, brain MRI Tumor marker Sputum AFB staining and TB culture, TB PCR test TB quantiferon PFT, ACE level check

Initial assessment & plan #3. Known HTN #4. Known dyslipidemia #5. Known GERD #6. Known gastritis P) 기존 medication 유지 및 observation

Clinical course

Chest CT (3/26)

Abdomen CT (3/26)

PFT (3/29)

PET CT (3/29)

검사명결과 유무 AFB StainNegative TB CulturePending 결핵균 특이항원 (INF–r) Negative TB/NTM RT PCRNegative/ Negative CA U/mL CA U/mL CEA ng/mL AFP 1.79 ng/mL ACE 102 U/L 24hr urine Ca 79 mg/day

HD #6 (4/2) #1. Cough, sputum, rhinorrhea symptoms #2. Disseminated reticulonodular opacities of entire lungs #3. Incresed uptake in multiple sites (PET scan) #4. Increased ACE level A) R/o hematogenous lung metastasis, r/o sarcoidosis P) Biopsy Ophthalmologic evaluation

Wedge resection Bx via VATS Lt. (4/4)

TB PCR(-)

Ophthalmologic evaluation Conjunctiva Injection (-) Ciliary injection (-) Cornea : Clear Iris & Pupil : Isocoric pupil with PLR (++/++) Anterior chamber reaction (+) Fundus : No definite abnormality (C/D ratio 0.3) A) Anterior chamber reaction P) Uveitis 는 없으나 발전 가능성 있어, f/u evalution 필요

Cardiac echo

HD #16 (4/12) #1. Cough, sputum, rhinorrhea symptoms #2. Non-caseating granulomas A) Sarcoidosis P) Steroid therapy

2/22 3/26 IG opd 방문 IG 4/4 Biopsy PET-CT Metastatic Tumor ? Sarcoidosis? IP 3/28 Abdomen CT Spleen meta r/o 월 중순경 C/ S/ R(+) 1 달간 지속 호흡기내과 의뢰 Steroid therapy 입원기간 Clinical course 입원기간 Clinical course VATS biopsy (LUL lingular segment) Non-caseating granuloma HRCT Multiple nodules 4/12 Cardiac echo 4/10

4/236/11 OPD Prednisolone 20mg 5/ Discharge Prednisolone 30mg Chest CT 7/13 Clinical courseClinical course OPD Prednisolone 10mg OPD Prednisolone 10mg (EOD) OPD Prednisolone 10mg (EOD) 9/24 OPD Prednisolone Stop

Final Diagnosis #1. Sarcoidosis #2. Known HTN #3. Known dyslipidemia #4. Known GERD #5. Known gastritis