2022-11-09 (三) 15:00 ~ 17:00

2022年南區胸腔病例討論會

摘要課程表

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	2022年11月09日	15:00〜17:00	梁宇峰、楊明泉等

 場次1

15：00-15：30討論病例

Name: 王xx

Age : 78 year old femen

Chart NO: 32xx98

C/C : chest discomfort and cough for few days

Past history :

1. Hypertension with oral medication by Norvasc(5) 1# QD po control at LMD

2. Hyperlipidemia with oral medication by Synpid 1# QD po control at LMD

3.Type 2 diabetes mellitus : deniend

4. Heart disease : deniend

5. Renal disease : deniend

Operation:

1. Cataract in both eyes s/p op years age

2. Left lung mass s/p op years age

3. Right femoral neck fracture ( due to fall down) s/p op and artificial joint replacement at 邱綜合 hospital on 2018

家族史：

No liver diseases, hypertension, CVA, Diabetus Mellitus, TB, arthritis for family history

旅遊史：

  T: travel history: Nil. in recent three months

  O: occupational hitory: Businessman

  C: contact history: Nil

  C: cluster history: Nil

個人病史：

[Personal History]--> Occupation:Businessman  Education:college  Marital status:married  Exercise:no  Alcohol:no  Tobacco:no  Coffee:no  Tea:no  Betel nut:no  Drugs:no  Allergy:never 敘述:NKA,

查無30天內旅遊或接觸史資料

動物接觸史:無家族史：

denied family any systemic disease

理學發現：

2021/01/04-> GOT ： 13 U/L ; GPT(ALT) ： 7 U/L ; Bil(T) ： 0.39 mg/dL ; Alb ： 3.77 g/dL ; BUN ： 12 mg/dL ; Cre(B) ： 0.40 mg/dL ; eGFR ： 154.4 ml/min/1.73 m^2 ; Na ： 141 meq/L ; K ： 3.5 meq/L ; Ca ： 7.6 mg/dL ; Procalcitonin (PCT) ： 0.34 ng/mL ; WBC ： 5.4 10 ^3/uL ; RBC ： 3.64 10 ^6/uL ; Hb ： 11.5 g/dL ; Hct ： 33.7 % ; Platelet ： 479 10^3/uL ; MCV* ： 92.5 fL ; MCH ： 31.5 pg ; MCHC* ： 34.0 g/dL ; RDW ： 12.7 % ; MPV ： 6.8 fl ; Neutrophil ： 53.1 % ; Lymphocyte ： 30.5 % ; Monocyte ： 14.1 % ;

2020/12/29-> BUN ： 11 mg/dL ; Cre(B) ： 0.42 mg/dL ; eGFR ： 145.9 ml/min/1.73 m^2 ; Na ： 142 meq/L ; K ： 3.1 meq/L ; Procalcitonin (PCT) ： 16.93 ng/mL ; WBC ： 4.6 10 ^3/uL ; RBCNeutrophil ： 47.1 % ; Lymphocyte ： 35.3 % ; Monocyte ： 15.8 % ;

2020/12/24-> CEA ： 7.2 ng/ml ; SCC ： 0.5 ng/ml ;

入院經過:                

  This 78-year-old female patient has had Hypertension and Hyperlipidemia with oral medication control and follow-up at LMD. According to the patient statement, she suffered from chest discomfort and cough for few days, she visited to 邱綜合 hoapital for help, follow-chest x ray showed right lung mass, thus, she was transferred to Dr. 梁宇峰 OPD further evaluation and treatment.

   Associated symptoms including of cough combine a small amount of whietish sputum. Physical examination and include chest breath sounds: coarse in right midlung lung fields, clear in left lung fields; heart sounds: normal and no murmurs; abdomen soft and no tenderness. No chest pain or chest tightness, hoarseness, epigastralgia, weight loss, fever, sweating, myalgia, sore throat, rhinorrhea, nasal congestion,  poor appetite, nausea, vomiting, dysuria. And the chest X-ray report showed mass lesion abuting right hilum. Under impression of Right hilum lesion, suspect pneumonia or malignency. Due to above problems, she was allowed to receive further evaluation and management.

15：30-16：00討論病例

Name: 孫xx

Age : 60 year old man

Chart NO: 57xx56

C/C : Sudden onset SOB and dyspnea in  yesterday (2021/03/30)

Past history :

11.2021/03/04 PATHOLOGIC DIAGNOSIS:Non-small cell carcinoma, favor squamous cell carcinoma ---- lung, right upper lobe, CT-guided biopsy.

->squamous cell carcinoma  in Right upper lung cancer with bilateral pulmonary hilar and  mediastinal lymph nodes and right pleura metastases with malignant effusion (T2bN3M1a, stage IVA) s/p pigtail drainage on 2021/02/22-03/01 and chemotherapy with Docetaxel weekly+Cisplatin on 2021/03/16

2.Hypertension with medications treatment (心臟內科/蔡坤炎)

   Bisoprolol  5mg/tab(Concor) 1.00 tab QD PC * 28

   Lercanidipine 10mg/tab(Zanidip)(降血壓) 1.00 tab BID PC

   Doxazosin  4mg/tab(Doxaben XL) 1.00 tab QD PC

   Valsartan 80mg/tab(Diovan) 1.00 tab QD PC

   Atorvastatin 10mg/tab(Tulip) 1.00 tab QOD PC

3.Rheumatoid arthritis  (風濕免疫科/Dr.孫俊明)

   Prednisolone 5mg/tab(Predonine) 1.00 tab QD PC

   Folic acid  5mg/tab(Folic acid) 1.00 tab QD PC

   Clonazepam 0.5mg/tab(Rivotril) 1.00 tab HS

   Sulfasalazine 500mg/tab(Salazine) 2.00 tab BID PC

   #Azathioprine 50mg/tab(Imuran) 1.00 tab QD PC

   Omeprazole 20mg/cap(Omeprotect) 1.00 cap QD AC

4.Osteoarthrosis,bilateral knees, with medications and local injection treatment at clinic

5.Chronic insomnia

6.Operation history:

Technique of Operation：Total hip arthroplasty (Osteonic, stem: 10#, Cup:52mm, Insert: 32mm; head+neck: 32+0mm, ceramic on PE) on 2018/12/07

 hemorrhoid post op, 2015/11

 colon polyp post op

家族史：

Father : hypertension

旅遊史：

   T: travel history: Nil. in recent three months

   O: occupational hitory: Nil

   C: contact history: Nil

   C: cluster history: Nil個人病史：

[Personal History]--> Occupation:Others  Education:elementary  Marital status:widow  Exercise:no  Alcohol:no  Tobacco:no  Coffee:no  Tea:no  Betel nut:no  Drugs:Anti-H/T  Allergy:(+) 敘述:tramadol  動物接觸史:無 

個人病史：

[Personal History]--> Occupation:Others  Education:illiteracy  Marital status:widow  Exercise:regular  Alcohol:no  Tobacco:no  Coffee:no  Tea:no 

Betel nut:no  Drugs:Anti-H/T  Allergy:never ,敘述:NKA,敘述:NKA 

動物接觸史:無  

extremities:normal  Nail:normal 

理學發現 :

2021/04/05-> ALP ： 52 U/L ; Bil(T) ： 0.37 mg/dL ; BUN ： 15 mg/dL ; Cre(B) ： 1.30 mg/dL ; eGFR ： 56.1 ml/min/1.73 m^2 ; Na ： 136 meq/L ; K ： 4.1 meq/L ; CRP ： 1.56 mg/dL ; WBC ： 8.2 10 ^3/uL ; RBC ： 3.93 10 ^6/uL ; Hb ： 11.3 g/dL ; Hct ： 33.8 % ; Platelet ： 308 10^3/uL ; Neutrophil ： 68 % ; Lymphocyte ： 5 % ; Monocyte ： 13 % ; Metamyelocyte ： 7 % ; Myelocyte ： 6 % ;

2021/04/02-> Na ： 127 meq/L ; K ： 4.1 meq/L ; CRP ： 6.24 mg/dL ; WBC ： 4.7 10 ^3/uL ; RBC ： 3.42 10 ^6/uL ; Hb ： 9.9 g/dL ; Hct ： 29.2 % ; Platelet ： 267 10^3/uL ; MCV* ： 85.3 fL ; MCH ： 29.0 pg ; MCHC ： 34.0 g/dL ; RDW ： 13.9 % ; MPV ： 7.6 fl ; Neutrophil ： 69.0 % ; Lymphocyte ： 11.5 % ; Monocyte ： 19.4 % ;

2021/04/01-> Na ： 129 meq/L ; K ： 4.2 meq/L ; Pleural-appear ： yellow-cloudy  ; Pleural-Glu ： 146 mg/dL ; Pleural-RBC ： 2850 cumm ; Pleural-WBC ： 436 cumm ; NE (體液) ： 61 % ; Lym (體液) ： 17 % ; M?(體液) ： 22 % ; Eos (體液) ： 0 % ; DC-other(體液) ： mesothelial cell:2/100DC  ; Polynuclear:Mononuclear ： -  ; WBC ： 4.4 10 ^3/uL ;

2021/03/31-> GOT ： 20 U/L ; GPT(ALT) ： 19 U/L ; BUN ： 15 mg/dL ; Cre(B) ： 1.31 mg/dL ; eGFR ： 55.6 ml/min/1.73 m^2 ; Na ： 124 meq/L ; K ： 3.9 meq/L ; Troponin I(AMI≧500pg/mL) ： 388.5 pg/mL ; CRP ： 10.83 mg/dL ; WBC ： 2.5 10 ^3/uL ; RBC ： 3.32 10 ^6/uL ; Hb ： 9.6 g/dL ; Hct ： 28.3 % ; Platelet ： 208 10^3/uL ; Neutrophil ： 56.9 % ; Lymphocyte ： 22.7 % ; Monocyte ： 19.8 % ; Eosinophil* ： 0.0 % ; Basophil* ： 0.5 % ;

2021/03/30-> GOT ： 20 U/L ; GPT(ALT) ： 18 U/L ; BUN ： 17 mg/dL ; Cre(B) ： 1.28 mg/dL ; eGFR ： 57.1 ml/min/1.73 m^2 ; WBC ： 1.4 10 ^3/uL ; RBC ： 3.26 10 ^6/uL ; Hb ： 9.5 g/dL ; Hct ： 27.9 % ; Platelet ： 172 10^3/uL ; Neutrophil ： 50 % ; Lymphocyte ： 40 % ; Monocyte ： 10 % ;

2021/03/23-> GOT ： 23 U/L ; GPT(ALT) ： 21 U/L ; BUN ： 39 mg/dL ; Cre(B) ： 1.21 mg/dL ; eGFR ： 61.2 ml/min/1.73 m^2 ;

入院經過:

This 61 y/o male had  history of Non Samll cell carcinoma in Right upper lung cancer with bilateral pulmonary hilar and  mediastinal lymph nodes and right pleura metastases with malignant effusion (T2bN3M1a, stage IVA) s/p pigtail drainage on 2021/02/22-03/01 and chemotherapy with Docetaxel weekly+Cisplatin on 2021/03/23

and Rheumatoid arthritis & hypertension with medicines control in our hospital OPD follow up.

  He suffer from  Sudden onset SOB and dyspnea in  yesterday (2021/03/30), also has fever upper to 39c , poor intake , wenkness  was noted,  there was no chill , nasal discharged ,abdomen pain , water stool  . he went to our chest OPD on 03/30 ,f/u lab data shows Leukopenia ( WBC :1400 ) ->Lenograstim 250 (G-CSF) inj. 250mcg sc st on 03/30 .however , he have SOB in progression in  after go home, today,  because the SOB in persistent was noted, then he went to our ER for help on 2021/03/31. at ER, CXR follow-up shows massive pleural effusion in right lung , lab data shows  Leukopenia  ( WBC :2500) , under impression of lung cancer with right massive pleural effusion in progression  and Leukopenia , suspect Chemotherapy related , he was admitted for further evaluation and management.

16：00-16：30討論病例

Name: 陳呂xx

Age : 83 year old femen

Chart NO: 39xx62

C/C : sudden onset of SOB since this morning

Past history :

(1).Hypertension Norvasc(5) 1# po qd

(2).Skin cancer(basal cell carcinoma)

(3)Rectal cancer

Allergy history: NKA

Alcohol: none

Smoking: none

Travel history in recent 3 months: Nil

Animal contact history: Nil

Hypertension was diagnosted>10 years with regular control,

Rx: Losart(50)1# po qd, Norvasc(5) 1# po qd

家族史：

denied family any systemic disease

旅遊史：

none

個人病史：

[Personal History]--> Occupation:Others  Education:elementary  Marital status:widow  Exercise:no  Alcohol:no  Tobacco:no  Coffee:no  Tea:no  Betel nut:no  Drugs:Anti-H/T  Allergy:(+) 敘述:tramadol  動物接觸史:無 

理學發現：

2020/11/08-> GOT ： 23 U/L ; GPT(ALT) ： 8 U/L ; BUN ： 7 mg/dL ; Cre(B) ： 0.40 mg/dL ; eGFR ： 152.8 ml/min/1.73 m^2 ; Na ： 131 meq/L ; K ： 3.8 meq/L ; Ca ： 8.3 mg/dL ; CRP ： 10.87 mg/dL ; WBC ： 14.2 10 ^3/uL ; RBC ： 4.29 10 ^6/uL ; Hb ： 13.1 g/dL ; Hct ： 38.6 % ; Platelet ： 401 10^3/uL ; MCV* ： 90.0 fL ; MCH ： 30.6 pg ; MCHC* ： 34.0 g/dL ; RDW ： 13.4 % ; MPV ： 6.9 fl ; PT ： 13.7 sec ; PT (INR) ： 1.23 INR ; PT (Ctrl) ： 11.0  ; APTT ： 28.2 sec ; APTT (Ctrl) ： 29.0 sec ;

入院經過:                

   This 83 year-old female who has (1).Hypertension (2).Lung cancer(Adenocarcinoma) with Irresa treatment (3)Rectal cancer (4).Skin cancer(basal cell carcinoma), suffered from sudden onset of SOB since this morning. Associated symptoms including dry cough, dizziness. There was no sputum, fever, chills, sorethroat and was no nausea, vomiting, diarrhea, dysuria.

At ER, CXR arranged. The Lab revealed leukocytosis with hypo-Na. Vital signs revealed 38.1C/65/18 BP: 131/67mmHg, SPO2: 98. Blood culture checked prior to antibiotics(Flumarin 1gm ivd stat). Under impression of 1.Lung cancer(Adenocarcinoma) with left minimal pleural effusion and lung to lung metastasis, stage IV ,Due to above problems, she was admitted.

   After admission, kept oxygen supply. Collect sputum routint/culture/Acid fast stain and TB culture x 3sets survey. Antibiotic sent Brosym 4000mg Q12H on 11/08-11/10 to Cravit 750mg QD and Doripenem 1000mg Q8H since 11/10-11/11 for infection control. Suggest on NG for nutritional support but her family refused. Adequate hydration supplement for renal function protection and nutritional support. Consultation Hospice for pain control and terminal staging.  Pain control by Ultracet 0.5# Q6H po sent to Morphine 3mg Q6H SC. Morphine and Bronchodilators inhalation, steroid, Antitussive, Expectorant and Antipyretic analgesic was given for symptoms relief. Howere her condition became worsening, fully explained critical condition to her families, they early DNR was already signed (全拒，院宣). Sudden onset of heart rate showed standstill, respiratory pattern showed apnea, BP?, pupil sized revealed dilatationthe patient expired at 23:07 on 2020-11-11.