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[의학과][종양내과] 71세 여성환자 입원 사례(On Service Note)에 대한 자료입니다.
목차
1. Chief Complaint
2. Present Illness
3. Past History
4. Family History
5. Review of System
6. Physical Examination (2010. 04. 19)
7. Intial Impression
8. Initial Plan
9. Initial lab data
10. Image Study
11. Diagnosis
12. Plan
13. Progress
본문내용
뇨 검사 (10/04/17)
Routine U/A with Microscopy
S.G. 1.008 1.0~1.03
pH 7.5 4.5~8.0
Protein - -
Glucose - -
Ketone - -
Blood,RBC - -
Urobilinogen +/-(0.1) +/-(0.1)
Bilirubin - -
Nitrite - -
WBC +/- - *
Color LT.YELLOW
Turbidity Clear Clear
Microscopy RBC (FCM) None seen(1.6) 0-2 (0-16.6) /HPF (/μL)
WBC (FCM) 3-5(17.6) 0-2 (0-16.6) /HPF (/μL)
Epithelial cell (FCM) None seen(1.6) None seen, A few (0-55.6) /HPF (/μL)
Cast (FCM) None seen(0.0) None seen (0-6.9) /LPF (/μL)
Bacteria (FCM) None seen(0.0) None seen (0-100) /HPF (/μL)
SEDIMENT 1 (Microscopy) - -
SEDIMENT 2 (Microscopy) - -
SEDIMENT 3 (Microscopy) - -
일반화학 (10/04/17)
Routine
Chemistry Calcium 9.1 8.5~10.5 mg/dL
Inorganic P 3.9 2.5~4.5 mg/dL
Glucose 109 70~110 mg/dL
BUN 8.0 5.0~25.0 mg/dL
Creatinine 0.66 0.50~1.40 mg/dL
Uric acid 3.4 2.5~7.5 mg/dL
Cholesterol 163 100~220 mg/dL
Total protein 6.5 6.0~8.0 g/dL
Albumin 4.6 3.3~5.3 g/dL
Alk.phospatase 35 38~115 IU/L L
AST(GOT) 20 13.0~34.0 IU/L
ALT(GPT) 16 5.0~46.0 IU/L
T.billirubin 0.4 0.2~1.2 mg/dL
Na 140 208 Mmol/L
K 4.1 2.43 Mmol/L
Cl 102 136 Mmol/L
tO2 27 4.5 Mmol/L
10. Image Study
Chest PA (4/17)
No newly developed lesion to suggest metastasis or active lung parenchymal disease
Abdomen Flat, Upright (4/17)
No abnormal gas, calcification, or mass shadow in the abdomen-pelvis
11. Diagnosis
Malignant melanoma stage IIIB(T4bN2bM0)
Metastasis to lymph node lower limb
12. Plan
6th Dacabazine CTx
6번째 Dacarbazine CTx(4. 18 ~4.21) 실시 예정이며 환자 complication 없을 시 4월 23일 퇴원 예정입니다.
13. Progress
S : “졸립고 계속 잠만 와요. 하루 종일 간지럽고 약을 먹어도 변비가 좋아지지 않아요.”
O :
A :
Malignant melanoma stage IIIB(T4bN2bM0)