소개글
[의학과] Dyspnea를 주소로 내원한 남성환자 사례에 대한 자료입니다.
목차
Chief complaint
Present illness
Review of system
EKG
Chest X-ray
Initial lab. finding
Impression and plan
Chest X-ray HD#1
Progress note
Chest X-ray HD#2
Progress note
Chest X-ray HD#7
HRCT
Operation note
Operation procedure
병리
Progress note
Pneumothorax
분류
Pathogenesis
치료
Operation indication
Reference
본문내용
Chief complaint
dyspnea onset) 1주일 전
Present illness
특이병력 없는 30세 남자, 내원 1주일 전부터 dyspnea, 약한 흉통 발생하여 감기라 생각하고 종합감기약 복용하였으나 증상 반복되어 local 병원 방문하였고, 기흉 있다는 이야기 듣고 큰 병원 권유 받아 본원 ER 통해 TS 입원함.
1. Pneumothorax, most likely
2. Pulmonary tuberculosis, less likely
3. pneumonia(fungal, bacterial, viral), less likely
plan>
EKG
Chest x-ray
CBC/DC, chemistry, UA, ABGA
Tb gram & AFB stain, culture
Fungus culture
If needed, chest CT
Impression>
Primary spontaneous tension pneumothorax, Left, 1st attack
Plan>
응급 needle decompression
Chest tube insertion
Pain control
High O2 supply
Hydration
Bed Rest with semi Fowler position
Chest x-ray f/u
ABGA f/u
HRCT
OP date : 2010.5.4
Pre-OP Dx : Primary spontaneous pneumothorax, Left, 1st attack
Post-OP Dx : 상동
OP name : wedge resection by VATs, Lt.(#2)
OP findings
No adhesion or adhesion band
No pleural effusion
Small bullaes on superior segment of LLL
Small bullae and bullous change on apex of LUL
참고문헌
의대생을 위한 흉부외과학, 제 2판, 김원곤, 고려의학, 2000
Surgery of the Chest, 7th Edition, sabiston & spencer
Spontaneous pneumothorax, STEVEN A. SAHN,M.D., AND JOHN E. HEFFNER,M.D.,NEJM, Volume 342:868-874 March 23, 2000 Number 12.
Primary spontaneous pneumothorax in adults, Richard W Light, 2009, uptodate.com