소개글
[의학과][종양내과] 58세 남성환자 입원 사례(on service note)에 대한 자료입니다.
목차
1. Chief complain
2. Present illness
3. History
4. Review of system
5. Physical exam
6. Initial Lab
7. Image study
8. Impression & Plan
9. Progress note
본문내용
6. Initial Lab (04.18)
CBC 10610/11.8/37.2/206K
Neutrophil 59.7%
혈액응고 PT 10.9/ INR 0.96/ aPTT 32.1
일반화학 E’ 138/4.5/101/25 Glucose 113
BUN/Cr 15.7/0.86 Alk.Phos 198
Uric acid 4.2 T.bilirubin 0.4
OT/PT 23/17
종양표지자 CEA 2.18
7. Image study
Chest PA(04.18) :
No newly developed lesion to suggest metastasis or active lung parenchymal disease.
Abdomen Flat, Upright(04.18) : Normal
CT Abd+Pel Dynamic (04.18)
Rectal cancer with liver metastases post-op, s/p RFA.
Loculated fluid collection in the anterior aspect of Lt. lobe of the liver.
No evidence of local tumor recurrence from RFA-treated lesion.
No newly appearing lesion in the abdomen and pelvis.
CT Chest & HR Double Study(04.18)
- No evidence of intrathoracic metastasis.
- Comparing to prior chest CT (2010-01-15) : No evidence of metastasis or active parenchymal consolidation in both lung parenchyma. No LNE in the hilar, mediastinum and both supraclavicular fossa. Left thyroid nodule.
8. Impression & Plan
Impression
- rectal cancer
- liver metastasis
Plan
- APCT, Chest CT f/u
- Supportive care (BT < 37.5, Diarrhea =< grade 1)
- Chemo Tx – 15th A+ FOLFOX (10.4.20-21)(oxaliplatin skip) q2wks
9. Progress note
#HOD2 (10.04.19)
S
- “몸 상태가 괜찮아요”
O
- CBC: 10610(59.7%)/11.8/206k
- E’ : 138/4.5/101/25
- BUN/Cr: 15.7/0.86
- OT/PT/T.bil: 23/17/0.4
- BT 36.7
- APCT : Loculated fluid collection in the anterior aspect of Lt. lobe of the liver.
A
- Fluid collection in Lt. liver
P
- 경과 관찰
- general condition 호전시 CTx 시행 고려
#HOD3 (10.04.20)
S
- “괜찮아요.”
O
- BSA : 1.83 Wt : 69.4kg
- BT 36.7
A
- Stable condition
P
- CTx 시행
Avastin 5mg/kg-> 300m만 처방 D1 for 90min
Eloxatin 85mg/m2->155.55mg