[혈종내과]Hemato-Oncology

소개글

Hemato-Oncology에 대한 Case Report
환자에 대한 정보를 알아본 뒤 Disease Review를 통해 진단과 치료, 향후 전망에 대해서 알아본다.

목차

<Patient Information>
-Chief Complaint
-Present Illness
-Personal History
-Past History
-Family History
-Review of Systems
-Physical Examination
-General appearance
-Skin
-Nect
-Chest
-Abdomen
-Back & Extremity
Problem List
Assessment
Plan
Hospital Course
＜Disease Review>

본문내용

Chief Complaint
For 5th CTx(3rd hyper-CVAD CTx)

Present Illness
F/52 환자 2004년 10월 Dyspnea on Exertion, headache, dizziness 있어 BM biopy에서 ALL 진단 받고 지금까지 4차 chemo Tx 시행 받았으며(2nd hyper-CVAD, 2nd high dose MTX-ara C), 금일 5차 chemo Tx(3rd hyper-CVAD CTx) 시행받기 위해 입원함

Personal History
Occupation ( - )
Smoking / alcohol ( - / - )
Known drug / allergy history ( - )

Past History
Adm. & Op. history ( + )
for chemotherapy in HYHO
HTN / DM / Pul. tbc / Hepatitis ( - / - / - / - )

Family History
HTN / DM / Pul. tbc / Hepatitis ( - / - / - / - )

Review of Systems
General weakness ( + ) Easy fatigue ( + )
Fever/Chill ( - / - ) Night sweat ( - )
Wt. loss ( - ) Insomnia ( - ) Headache ( - ) Otalgia ( - )
Blurred vision ( - ) Sore throat ( - ) Dry mouth( - ) Rhinorrhea( - )
Cough/Sputum ( - / - ) Hemoptysis( - )
DOE ( + ) SOB ( - ) PND ( - ) Orthopnea ( - ) Chest pain ( - )
Chest tightness ( - ) Palpitation ( - ) Anorexia( + )
Nausea/Vomiting ( + / - )
Indigestion ( - ) Postprandial fullness ( - )
Epigastric pain ( - ) Abdominal pain ( - )
Hunger pain ( - ) Constipation ( - ) Diarrhea ( - ) Hematemesis ( - )
Hematochezia ( - ) Melena ( - ) Frequency ( - ) Nocturia ( - )
Oliguria ( - ) Dyspnea ( - ) Hematuria ( - ) Urgency ( - )
Hesitency ( - )
Myalgia ( - ) Arthralgia(-)

참고 자료

HARRIEON`S PRINCIPLE of INTERNAL MEDICINE 16th Edition