[의학과][종양내과] 50세 여성환자 입원 사례(On Service Note)

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[의학과][종양내과] 50세 여성환자 입원 사례(On Service Note)에 대한 자료입니다.
목차
1. Chief Complaint
2. Past History
3. Family History
4. Present Illness
5. Review of System
6. Physical Examination
7. Intial Impression
8. Initial Plan
9. Image Study
10. Lab Data
11. Progress note
본문내용
CXR (2010.04.10)


No active lung disease.

Abdomen Flat Upright (2010.04.10)



Feces in large bowel loops.
Contrast material in both urinary tracts without gross abnormality


CT Abd+Pel Dynamic (contrast) (2010.04.10)

Compared with previous CT scan taken on Feb 16,

Slightly increase in size and number of omental seeding nodules and peritoneal nodular lesions and further thickening of Rt. lower pleura.
Minimal amount of ascites.
IMP : Minimally progression of disease.


CT Chest & HR Double Study(contrast) (2010.04.11)


Compared with prior chest CT taken on 2009-01-28.

Newly developed minimal pleural effusion in both lungs.
No evidence of metastasis on the lung parenchyma.
Subsegmental collapses at the RML and Lt. lingular segment. No change of a tiny nodule in RML, suggest granuloma.
No lymph node enlargements on hilum, mediastinum and supraclavicular fossa.
The upper abdomen is not remarkable.
IMP: Newly developed minimal pleural reaction, cause uncertain.


10. Lab data
일반혈액 (2010.04.10)

검사명 결과 참고치 단위 판정
CBC WBC COUNT 2.96 4.0~10.8 10^3/μL L 
RBC COUNT 3.40 4.5~6.1 10^6/μL L
Hemoglobin 10.7 13.0~17.0 g/dL L
Hct 33.2 40.0~52.0 % L
MCV 97.6 80.0~98.0 fL  
MCH 31.5 27.0~33.0 pg
MCHC 32.3 33.0~37.0 g/dL L 
RDW 16.6 11.5~14.5 % H