내과케이스

목차

Ⅰ서론
1. 대상자 소개
2. 대상자 병력
3. 대상자 신체검진

Ⅱ 본론
1. Disease Description
1) Lung Ca
2) COPD(Chronic Obstructive Pulmonary Disease)
: 만성 폐쇄성 폐질환
3) Unstable angina
4) DM(Diabetes Mellitus)
2. 환자 투약약물
3. 방사선소견
4. 임상검사 및 진단적 검사 결과

본문내용

lobe.
4. Suggestive finding of anthracofibrosis.
3) Chest CT CE (2004/04/12)
- 2002년 11월 27일 HRCT에서 관찰되던 right upper lobe post. segment medial side의 mass lesion은 그 크기가 증가됨.
- Emphysematous change를 보이는 양측 lung과 left lower lobe의 bronchiectatic change 변화 없음.
- Aorta wall을 따라 diffuse atherosclerotic change 관찰되며 aortiec arch의 lower lateral wall을 EK라 penetrating ulcer의 형성이 관찰됨.
4) Chest P-A view (2004/05/16)
- As compared with previous radiography, there is no significant gross interval change.
5) Whole Body Bone Scan (2004/05/19)
- Whole body bone scan was obtained following administration of 20 mCi of Tc-9 9m HDP.
- The study shows mild activity at mid-thoracic spine (approximately T7)
[impression] Mild uptake lesion at T7, degenerative change more likely.
6) Chest P-A & Rt Lat view (2004/05/19)
- Development of some patchy pneumonic consolidation in superior segment of LUL.
- No other gross interval change.
4. 임상검사 및 진단적 검사 결과
1) 혈액가스검사(Blood Gas Analysis)
검사명
5/13
5/14
5/19
참고치
단위
Hemoglobin
10.1(L)
11.0(L)
110.9(L)
12.7~17.0
g/dl
Hematocrit
30(L)
32(L)
35(L)
38~52
%
PH
7.398
7.385
7.370
7.32~7.45
PCO2
28.5(L)
35.7
38.0
35.0~45.0
mmHg
PO2
57.9(L)
72.3(L)
71.6(L)
75.0~100.0
mmHg
Ca
0.95(L)
1.16
1.15
1.13~1.32
mmol/l
Base Excess-ECF
-6.6(L)
0.9
-3.8(L)
-2.0~2.0
mmol/l
Base Excess-Blood
-5.7(L)
0.8
-3.4(L)
-2.0~2.0
mmol/l
Standard bicarbonate
19.7(L)
25.2
21.6(L)
22.0~26.0
mmol/l
Actual bicarbonate
18.4(L)
25.7
21.5(L)
22.0~26.0
mmol/l
Total CO2
19.4(L)
25.2
22.6(L)
23.0~26.0
mmol/l
O2 Saturation
87.9(L)
94.2
94.6(L)
96.0~97.0
%
O2 Content
14.4(L)
13.8(L)
15.7(L)
16.0~23.0
ml/dl
nCa"(normalized)
1.15
0.95
1.14
mmol/l
Anion GAP
19.1
11.7
16.4
2) Routine CBC
검사명
5/14
5/17
5/19
참고치
단위
WBC
7.09
6.09
12.76(H)
4.0~10.0
10^9/L
RBC
4.84
4.50
4.48(L)
4.2~5.4
10^12/L
Hgb
12.3(L)
11.3(L)
11.3(L)
12.0~16.0
g/dl
Hct
38.2
34.2(L)
33.4(L)
36.0~46.0
Ratio
MCV
78.9
76.0(L)
74.7(L)
77~91
fL
MCH
25.4(L)
25.2(L)
25.2(L)
36.0~32.0
pg
MCHC
32.2
33.2
33.7
32.0~36.0
g/dl
RDW-cv
16.3(H)
15.8(H)
15.8(H)
11.8~14.8
**
PLT
444(H)
416
370
140~440
10^9/L
PDW
9.3(L)
56.2(H)
50.1(H)
15.5~17.5
fL
MPV
8.5
6.5(L)
7.1(L)
7.4~10.4
fL
NEUT
64.5
63.7
83.4(H)
40 ~ 80%
LYMPH
19.2
18.0
10.9(L)
15 ~ 50%
MONO
7.2
5.0
2.8
2 ~ 11%
EOSIN
8.5
11.1(H)
1.6
1 ~ 7%
BASO
0.6
0.4
0.3
0 ~ 1%
3) 생화학검사 - Blood(Serum)
검사명
5/13
5/14
5/19
참고치
단위
BUN
7(L)
6(L)
10
8~14
mg/dl
Creatinine
0.9
1.0
1.1
0.6~1.2
mg/dl
Na
147(H)
144
142
134~145
mEq/l
K
5.1
3.7
3.6
3.5~5.2
mEq/l
Cl
108(H)
109(H)
107
96~107
mEq/l
4) Liver Profile Ⅱ (간기능조합) - 2004.05.17
검사명
결과
참고치
단위
Total Protein
6.5(L)
6.7 ~ 8.3
gm/㎗
Albumin
3.2L
3.8 ~ 5.3
gm/㎗
Total Bilirubin
0.3
0.2 ~ 1.0
mg/㎗
AST (GOT)
18
10 ~ 33
U/L
ALT (GPT)
15
4 ~ 50
U/L
ALP
185
121 ~ 301
U/L
GTP
25
0 ~ 50
U/L
Creatinine
1.0
0.6 ~ 1.2
mg/㎗
Na
145
134 ~ 145
mEq/
K
4.0
3.5 ~ 5.2
mEq/
C
107
96 ~ 107
mEq/
5) 혈당수치
날짜
시간
결과
2004-05-11
6am
92
11am
160
4pm
112
9pm
139
2004-05-12
6am
88
11am
180
4pm
117
9pm
123
2004-05-13
6am
74
11am
98
4pm
76
9pm
168
2004-05-14
6am
83
- 이후 BST 측정은 D/C

키워드

내과케이스,   COPD,   만성패쇄성폐질환