[case report] AML(Acute Myeloid Leukemia) M2 환자의 케이스 및 Disease review

소개

의과대학 본과 3학년 혈액종양내과 임상실습 중 작성한 케이스 리포트입니다.
AML(Acute Myeloid Leukemia) M2 환자의 case(admission, progress note) 및 Disease review 작성하였습니다.

목차

1. Admission note
2. Daily progress note
3. Disease review

본문내용

Admission Note
Name :
Gender/Age : F/53
Chart No. :
Admission Date : 2015.8.10

[ Chief complaint ]
General weakness, Dizziness

[ Present illness ]
이전에 혈액학적 특이병력 없던 환자로,
내원 한달 전부터 general weakness, dizziness deveolop하여 LMC(안동병원) 방문하여 시행한 검사상 Leukemia 가능성 있다는 이야기 듣고, LMC 다시 방문하여 시행한 검사상 CBC 4.6-9360(280)-25k 및 PB smear blast (+)로 r/o acute leukemia 가능성 고려하여 본원 혈액종양내과 further evaluation 위해 입원

[ Past Hx ]
HTN/DM/hepatitis/Tb (-/-/-/-)
Alcohol (+) 주1회 소주 1병
Smoking (+) 1p/day for 30yrs
Family Hx (-)
OP Hx (+) Total hysterectomy

[ Review of Systems ]
(General)
fatigue/ general weakness / anorexia / edema / febrile, chilly sensation (-/+/-/-/-)
(Neurologic)
headache / dizziness / insomnia / unilateral limb weakness (-/+/-/-)
(ENT)
sore throat / voice change (-/-)
(Cardiovascular/Respiratory)
dyspnea / chest pain / palpitation / limb claudication (-/-/-/-)
cough / hemoptysis (-/-)
(Gastrointestinal)
abdominal pain / abdominal distension / diarrhea / constipation (-/-/-/-/-)
(Genitourinary)
dysuria / hematuria / impotency / menorrhea / dysmenorrhea (-/-/-/-/-)

참고자료

· 1. Harrison’s internal medicine, 19th edition, 2015
· 2. Charles A Schiffer, Clinical manifestations, pathologic features, and diagnosis of acute myeloid leukemia, 2015, UpToDate
· 3. Richard A Larson, Induction therapy for acute myeloid leukemia in younger adults, 2015, UpToDate