2020-12-09 (三) 15:00 ~ 17:00

2020年南區胸腔病例討論會

課程表

地  點：阮綜合醫院  B棟十樓大教室

地  址：高雄市苓雅區成功一路162號    連絡人：

                                                 內科部曾玲雯07-3351121#3075

                                                林莞茹專科護理師07-3351121#2258

場次	會議日期	時間	主持人
1	2020年11月11日	15:00〜17:00	梁宇峰、楊明泉等
2	2020年12月09日	15:00〜17:00	梁宇峰、楊明泉等

 場次2

15：00-15：30討論病例

Name: 洪xx

Age : 79 year old men

Chart NO: 130XX63

C/C : SOB and dyspnea passage for 2 weeks

Past history :

1.Type 2 Diabetes Mellitus for 30+ years, F/U at  our OPD.

2. Hypertension with regular medication tx. ?

3.Gastric ulcer withregualr PPI pariet at our.OPD

4.Chronic kidney diseae , stage III ?

5.Congestive heart failure with lasix  1# bid used by CVM OPD

5.operation : cataract  (OU) post operation

消化內科 (門診)Dr.陳錫榮:

Mosapride 5mg/tab(Mopride) 1.00 tab TID AC

Rabeprazole 20mg/tab(Pariet) 1.00 tab QD AC

Sitagliptin-Metformin 50mg-500mg/tab(JanuMet) 1.00 tab BID

Glipizide 5mg/tab(Glipizide) 2.00 tab BID AC

心臟內科 (門診)Dr.林韋丞 :( CHF )

Furosemide  40mg/tab(Rasitol) 1.00 tab BID PC

家族史：Not contributory

旅遊史： Denied recent travelling history

個人病史：

[Personal History]--> Occupation:Housewife 

Education:illiteracy 

Marital status:widow 

Exercise:no 

Alcohol:no 

Tobacco:no 

Coffee:no 

Tea:occasional 

Betel nut:no

Drugs:OHA;Others 

Allergy:unknown 敘述:NKA 

動物接觸史:無 

入院經過:

   This 79 y/o female patient  has had history of 1.Hypertension  2.Type 2 Diabetes Mellitus with regularly follow up. 3..Gastric ulcer withregualr PPI pariet at our.OPD  4.Chronic kidney diseae , stage III , 5.Congestive heart failure with lasix  1# bid used by CVM OPD ; Under impression of massive pleural effusion  in right side ,suspect Tuberculosis. empyema or malignancy .she was admitted for further study and mangement on 05/08.

  After  admitted ,We will keep well perfussion , oxygen support ,Empiric antibiotic Cravit 500mg ivd qd since 05/08; on 05/08 Under  the  echo guide,pleural effusion was tapping and drainage ->cloudy yellow pleural effusion had drained ; on 05/09 Chest CT without contrast was performed IMP:1.  In  favor  of  lung  cancer  in  right  upper lobe with  suspected  mediastinal  invasion,  left  supraclavicular  and  bilateral  mediastinal  lymph  node  metastases, lung  to  lung  metastases  and  malignant  pleural  effusion. T4N3M1a. The pleural routine and biochemical shows exudate and high  suspect malignancy ; blood CEA :171.0 ng/ml ; CEA-Pleural : 795.0 Pleural AFS : No AFB observed ; Pleural culture : not bacteria on 05/08 ;on 05/16 ,05/17 Fluid cytology plus cell block(Pleural effusion) 2 setes :Positive for malignant cells.The smear and cell block show a picture compatible with metastatic adenocarcinoma.We PET/CT ( whole body) arranged but the patient felts of dyspnea, So, not do ,* Pleurdosis #Bleomycin 60mg/vial(Bleocin)in pig tail  do on 05/20 ; EGFR do on 05/20( wait report) ;Information of Target therapy of # Iressa 250mg 1# qd/po since 05/21~,We removed pig tail on 05/23,The Family 要求出院 ,經主治醫師解釋病情宜繼續住院治療, (family說因在高雄無人力照顧,要轉去北部繼續治療) ,但family還是堅持出院, 所以於05/23辦理自動出院 .  15：30-16：00討論病例

Name: 吳X仁

Age :55 year-old, man

Chart NO: 139XX95

C.C.:

Dizziness with vertigo persistent for one week

Past history :

*DM diabetic mellitus type II ;

Hypension under H/T against for yrs at L.M.D.

*Personal habbit: smoking(-););alcohol:(-);betel nut:none

家族史：

*Denied cancer/Tumor /or hepatitis family history

旅遊史：

T.O.C.C.=Travel or contact history:denied, in recent 3 months ago

個人病史：

Occupation: Worker

Education: senior-high 

Marital status: married

Exercise:no 

Alcohol:no

Tobacco:no

Coffee:no 

Tea:no

Betel nut:no 

Drugs: Anti-H/T

Allergy:never 藥物:nil,,敘述:NKA 

動物接觸史:無 

Present Illuess:

    A 55-year-old male paptient complaiend that his vertigo with dizzienss, resntly.Blood pressure control poor under his won mdications at L.M.D.for yrs.

   He visited to our E.R., to checked G.C.S.:E4V5M6,pupil size L/R:2.0+/2.0+cons: alert ; unsteady gait  preswent(+)Casue by blurr visions (o.u.)without diplopia.He denied traumar, denied boby weight loss or over weight in recent months.Family history of cancer was also denied.

  Image of Brain revaled:one mass  lesion  (2.7cm)  of  heterogeneous  density  in  the  right  parieto-occipital  lobe  with  advanced  white  matter  edema ; Ct CT showed:a  large  tumor  (9.8x10.4x7.5  cm)  in  the  left  upper  lobe  with  parietal  pleural  invasion,  hilar  involvement,  partial  lobar  pulmonary  artery  encasement  and  subaortic  lymphadenopathy  and " Malignant"  lung  tumor  of  LUL  is  considered.   on 2019/05/16 at our E.R.

Abnormal abnormal data->  Bil(D)=0.23 mg/dL;  Cre(B)=0.52 mg/dL;  Na=135 meq/L;  CRP=1.58 mg/dL;  RBC=4.14 10 ^6/uL;  Hb=13.3 g/dL;  Hct=38.9 %;  MPV=7.4 fl;  Glucose=114 mg/dL on  2019/05/16

    Under imprssion of right  parieto-occipital  brain rumor ,suspected matestasis; Malignant"  lung  tumor   (L.U.L.), unspecified;hypertension.Thus he admitetd for further evaluation and manegement.

2019/05/16 abnormal data->  Bil(D)=0.23 mg/dL;  Cre(B)=0.52 mg/dL;  Na=135 meq/L;  CRP=1.58 mg/dL;  RBC=4.14 10 ^6/uL;  Hb=13.3 g/dL;  Hct=38.9 %;  MPV=7.4 fl;  Glucose=114 mg/dL

 

16：00-16：30討論病例

Name: 方xx

Age : 49 year old femen

Chart NO: 122XX96

C/C : more cough recently, breathless, request for chest film examination, then revealed LUL mass lesion

Past history :

denied any underlying disease

家族史：NIL

旅遊史：not in 3 months

個人病史：

**DM(-), HTN(-), Autoimmune disease(-), Endocrine disease(-), Systemic disease(-) Chronic infection(-), Trauma(-) Travel history(-), Animal contact(-) OP history(-)

Smoking(-), Alcohol consumption(-)

**OP history:

1.Right clavicle fracture s/p Open reduction internal fixation of clavicle on 2016/05/27 at 中正骨科 hospital

2.Coronary artery disease post catheterization with stent on 2015/08 at 小港 hospital, no drug control

No food or drug allergy

History of drinking: denied

History of smoking: chronic smoker 30 years. 50 years old

History of chewing betel nut: denied

家族史：

The family history was unremarkable.

旅遊史：

Contact history: Pets (-), similar S/S p't (-)

Travel history in recent 3months: denied

個人病史：

[Personal History]--> Occupation:Others 

Education:senior-high 

Marital status:married 

Exercise:no 

Alcohol:no  Tobacco:regular 

Coffee:no  Tea:no 

入院經過:

   This patient is a 49 y/o man with the history of Coronary artery disease post catheterization with stent in 2015. He has had more cough recently, breathless, request for chest film examination, then revealed LUL mass lesion. There was no associated fever, hemoptysis, chest pain, or abdominal discomfort. He went to our OPD where Chest film showed LUL mass, rule out LUL lung maligancy with right lung metastasis? The associated symptoms were as following : cough(+), sputum(+), rhinorrhea(-), nausea(-), vomiting(-), fever(-), chills(-), abdominal fullness(-), diarrhea(-), chest pain(-), chest tightness(-), dyspnea(+), headache(-), dizziness(-),  voiding burning sensation(-), dysuria(-), frequency(-), urgency(-), body weight loss(-). Under the impression of LUL mass, he was suggested to admission for further evaluation and management.

 After admission, general condition was survey. The patient received a series of examination. During hospitalization, CT of chest revealed Highly suspecting malignant lung tumor in the LUL with contralateral lung metastases, bilateral mediastinal nodal metastases and adjacent mediastinal invasion ＞＞ Tentative staging: T4 N3 M1a on 03/20. CT guided biopsy for LUL mass was performed smoothly on 03/21. MRI of head showed no strong evidence of intracranial abnormality, but bil. ICA siphon atherosclerosis on 03/21. PET of whole body was performed on 03/22. Now pathological report pending. During the whole course of hospitalization, there was no nosocomial infection nor complication. Then, he was suggested discharge with OPD appointment schedules for follow up.　adenocarcinoma.Immunohistochemical stain: TTF-1 (+) Ber-EP4 (+) P40 (-) ALK (-)Calretinin (-),We 告知病情for patient and her husband and 申請重大傷病 on 09/29; Check EGFR and Brain MRI , PET/CT ( whole body) was done on 10/01, 02. Pleuroderosis with Bleomycin was performed on 10/01, then remove pigtail catheter on 10/02. Change antibiotic regimen with Cefepime due to fever, up to 38 degree and TKI with Iressa was prescribed on 10/02. The 放射線腫瘤科Dr.汪昶佑 was consulted for MRI of head revealed brain metastasis on 10/02. Start Palliative whole brain RT for 3750 cGy/15 Fx. EGFR Q-PCR mutation analysis showed Exon 21 Point mutation [pL858R] on 10/04. Add 2nd antibiotic with Levfloxacin for infection control since 10/04. General condition is stable and fever did not re-occour after treatment. Hemodynamics was stabilized and her general condition got improved as times went on. During the whole course of hospitalization, there was no nosocomial infection nor complication.2018/10/08-> CRP ： 0.59 mg/dL ; WBC ： 7.8 10 ^3/uL ; RBC ： 4.77 10 ^6/uL ; Hb ： 10.1 g/dL 2018/10/11-> CK ： 17 U/L ; CK-MB(mass) ： <0.5 ng/mL ; Troponin I(AMI≧0.5) ： <0.017 ng/mL ; Pro-BNP ： 31 pg/mL  Then, she was suggested discharge with OPD appointment schedules for follow up.　for pain control. Now, fever subside. then follow-up chest image right pleural effusion more improved after  pig tail drainage on 07/02, We removed ig tail on 07/03. and will keep current treatment and monitor his vital signs and condition,

2019/03/21-> SCC ： 0.3 ng/ml ;

2019/03/20-> CEA ： 2.3 ng/ml ;

2019/03/19-> GOT ： 9 U/L ; GPT(ALT) ： 15 U/L ; Bil(T) ： 0.54 mg/dL ; Alb ： 3.73 g/dL ; BUN ： 10 mg/dL ; Cre(B) ： 0.82 mg/dL ; eGFR ： 99.9 ml/min/1.73 m^2 ; Na ： 138 meq/L ; K ： 3.6 meq/L ; CRP ： 1.82 mg/dL ; WBC ： 11.7 10 ^3/uL ; RBC ： 4.37 10 ^6/uL ; Hb ： 12.9 g/dL ; Hct ： 39.4 % ; Platelet ： 293 10^3/uL ; MCV* ： 90.1 fL ; MCH ： 29.5 pg ; MCHC* ： 32.8 g/dL ; RDW ： 13.9 % ; MPV ： 7.6 fl ; Neutrophil ： 63.9 % ; Lymphocyte ： 21.7 % ; Monocyte ： 5.5 % ; Eosinophil* ： 8.0 % ; Basophil* ： 0.9 % ; PT ： 12.8 sec ; PT (INR) ： 1.18 INR ; PT (Ctrl) ： 11.6  ; APTT ： 34.9 sec ; APTT (Ctrl) ： 30.0 sec ;