2024-12-11 (三) 15:00 ~ 17:00

2024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	2024年11月13日	15:00〜17:00	蕭惠元、楊明泉等
2	2024年12月11日	15:00〜17:00	蕭惠元、楊明泉等

 場次2

15：00-15：30討論病例

Name: xx 三進

Age : 69 year-old 

Gender: male

Chart NO: 1306219

C/C : mild cough for long terms

Past history :

1.Squamous cell carcinoma of R/T muccal mucosa,cT3N1M0, s/p wide excision on 2009/09/03, pT3N0M0,margin 5 MM,LN 0/33,4.1 CM, MUSCLE(+), S/P post R/T for 54 GY TILL 2009/12/4

2016/11/04 92001C 99

2017/01/06 92001C 99

2017/02/06 92001C 99

2017/11/06 92001C 99

2018/02/07 92001C 99

2018/06/22 92001C 99

2018/09/03 92001C 99

2018/09/19 92014C 25

家族史：

Nothing particular

旅遊史：

 T.O.C.C:

 T國外流行地區旅遊史：無

 O職業：無

 C動物接觸史：無

 C是否群聚：無

個人病史：

[Personal History]--> Occupation:Others  Education:senior-high  Marital status:married  Exercise:no 

Alcohol:occasional or social  Tobacco:occasional  Coffee:occasional  Tea:occasional 

Diabetes mellitus:denied

Hypertension:denied

Reflux  esophagitis,erosive  gastritis,duodenal ulcer  with  stenosis  of  PR with regular OPD F/U at our hospital.

Operation history:scalp tumor post excision on 94/10/6

Travel history:nil

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

家族史：

Family history:

- Month : nil

- Heart disease: nil

- Renal disease: nil

- HBV/HCV: nil

- Pulmonary disease: nil

- Cancer : nil

- Hypertension: nil

- Diabetes Mellitus: nil

個人病史：

[Personal History]-->

Education:junior-high 

Marital status: Marital

Exercise:no

Alcohol:no 

Tobacco:no 

Coffee: no

Tea: no  

Betel nut: no 

T: travel history: denied. in recent three months

O: occupational hitory: 退休

C: contact history: denied

C: cluster history: denied

 

理學發現：

[Vital Sign]

--> BH:164.5cm BW:.63.3kg

Temp:36.5C  BP:130/79mmHg

   PR:675/min RR:18 /min

 [General appearance]

--> Consciousness:alert  GCS:(E4V5M6 ) 

Development:normal 

Nourishment:well 

[Ear]

--> EEC:clear 

Hearing:normal 

 [Throat]

--> Tonsil:normal 

Tongue:normal 

Pharynx:normal 

[Nose]

--> Discharge:no 

Smelling:normal 

[Thyroid]

--> Size:non-palpable  Nodule:non  Tender: - 

 

[Eye]

--> Conjunctiva: not anemic 

Sclera: not icteric 

Pupil size, R't: 2mm  Pupil size, L't: 2mm 

   Light reflex (R/L):+/+  Shape:regular

[Lymph Node]

--> Cervical:non palpable 

Axillary:non palpable 

Inguinal:non palpable

    Consistency:soft

[Chest]

--> Contour:normal 

Percussion:reasonant 

Breathing sound: clear 

Heart beat:regular 

   Heart sound:no murmur 

 [Abdomen]

--> Liver: non palpable 

Spleen: non palpable 

Mass:no 

Tenderness:no 

   Bowel Sound:normal 

Rigidity:non 

Ascites:non 

Distension:no 

   Hernia:normal 

 [Spine & Extremities]

--> Spine:normal 

Upper extremities:normal 

Lower extremities:normal 

Nail:normal 

入院經過:

   A 69 year-old male case has had the past history of:1. Squamous cell carcinoma of R/T muccal mucosa,cT3N1M0, s/p wide excision on 2009/09/03, pT3N0M0, margin 5 MM,LN 0/33,4.1 CM, MUSCLE(+), S/P post R/T for 54 GY TILL 2009/12/4~with regualr Our OPD f/u; 2. hypertension with regular our OPD f/u. His ADL status was totally independent. TOCC:(-).

  According to patient's statement, he had suffered from dyspnea, cough with massive whitish sputum in recent months. He was routine follow-up chest image and  Chest CT on 11/30 revealed in  favor  of  lung  cancer  in  the  left  upper  lobe  with  suspected  left  hilar  lymphadenopathy. T2aN1. D/D:  TB,  fungal  infection,  etc. ; physical examination and associated symptoms, There was no fever,chill, headache, poor appetite, nasal obstruction, chest tightness, cold sweating, bloody or tarry stool passage, flank pain, burining urination, frequency and no body weight loss. Under above problems, he was admitted for further evaluation and management.

 15：30-16：00討論病例

Name:李XX

Age : 59 year-old male

Chart NO: 1675845

C/C : cough and body weight loss on 2-3 months (72-->55kg)

 

Past history :

1.Hypertension(-)

2.Type II diabetes mellitus:(+)

3.Hepatitis-B(-),Hepatitis-C(-)

4.Operation/ admission  history:

1.Low abdominal pain, suspect pancreatitis in 2020/11

 

家族史：

Denied family history of Hypertension, Type 2 diabetes mellitus, CAD, CKD, cancer

 

旅遊史：

TOCC:

Travel history in recent 3 months ago: denied

Occupation: denied

Contact history: Animal contact history: denied, Illness contact history: denied

Cluster: no family and friend with the similar symptoms

 

個人病史：

[Personal History]--> Occupation:Worker 

Education:junior-high 

Marital status:single 

Exercise:no 

Alcohol:quit 

Tobacco:quit 

Coffee:no 

Tea:no  

Betel nut:quit 

Drugs:no 

Allergy:never 敘述:NKA 

動物接觸史:無 

 

理學發現：

[Vital Sign]--> BH:166 cm BW:65 kg Temp:37.1 度C BP:170/118 mmHg

                PR:102 /min RR:18 /min

[General appearance]--> Consciousness:alert  GCS:(E4V5M6 )  Development:normal  Nourishment:well 

[Ear]--> EEC:clear  Hearing:normal  TM:not-test 

[Throat]--> Tonsil:normal  Tongue:normal  Pharynx:normal  Mouth floor:normal 

[Nose]--> Discharge:no  Smelling:normal 

[Thyroid]--> Size:non-palpable  Nodule:non  Tender:+ 

[Eye]--> Conjunctiva:not anemic  Sclera:not icteric 

Pupil size, R't:3mm  Pupil size, L't:3mm 

         Light reflex (R/L):+/+ 

[Lymph Node]--> Cervical:non palpable  Axillary:non  palpable 

Inguinal:non  palpable  Consistency:soft 

[Ophthalmosopic]--> Ophthalmoscopic:not-test 

[Neck]--> Neck:supple 

[Chest]--> Contour:normal  Percussion:reasonant  Breathing sound:clear 

Heart beat:regular  Heart sound:no murmur 

[Abdomen]--> Liver:non  palpable  Spleen:non  palpable  Mass:no  Tenderness:no 

Bowel Sound:normal  Rigidity:non  Ascites:non  Distension:no 

Hernia:normal 

[Genitalia]--> Genitalia:not-test 

[Rectal]--> Anus:not-test  DRE:not-test 

[Spine & Extremities]--> Spine:normal  Upper extremities:normal 

Lower extremities:normal  Nail:normal 

 

入院經過 :       

    The patient was admitted to our ward on 2024/02/26 due to cough and body weight loss on 2-3 months (72-->55kg), chest x-ray found RLL mass and admdission for biopsy.

    After admission, CT guided biopsy for RLL mass on 2/29, examination was arrange as abdominal sono, head MRI and chest CT. Impression of Favor lung cancer in the right lower lobe with left supraclavicular and bilateral mediastinal  lymph node metastases, malignant pericardial effusion, liver metastases and suspected left renal metastasis. T2bN3M1c. Pathology report revealed Non-small cell lung carcinoma, possible large cell neuroendocrine carcinoma. Port-a implantation on 2024/03/07 and chemotherapy since with #Etoposide inj. 100mg/5mL/vial(Fytosid) 128.80 on 3/8 ~ 3/10 and cispltin 96.60mg on 3/8. Post-chemotherapy, condition stable, patient was discharged and OPD follow up prescribed.

 

16：00-16：30討論病例

Name: 簡XX

Age : 42 year-old female

Chart NO: 2539592

C/C : Left upper back mass note for one month

 

Past history :

Rheumatoid arthritis for years medication control

Type 2 Diabetes Mellitus(-) 

Hypertension(-)

Hyperlipidemia(-)

Cancer(-)

Hepatitis B/C carriers (-)

Chronic/Tumors/Cancers/Genetic diseases (-)

Current medication :

慢性處方箋 次數：2024/01/09/ 0000 ~ 2024/4/2 ( Dr.孫俊明 )

Celecoxib  200mg/cap(Celebrex) 1.00 cap BID PC

Hydroxychloroquine 200mg/tab(Plaquenil) 1.00 tab BID PC

#Methotrexate 2.5mg/tab(Methotrexate) 6.00 tab QW PC

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

Leflunomide 20mg/tab(Arheuma) 1.00 tab Qd PC

 

Operation/hospitalization history:

YGH: Left posterior chest wall  tumor s/p excision on 113/03/02 under GA

 

家族史：

Denied family history of Hypertension, Type 2 diabetes mellitus, CAD, CKD, cancer

 

旅遊史：

TOCC:

Travel history in recent 3 months ago: denied

Occupation: worker (全聯)

Contact history: Animal contact history: denied, Illness contact history: denied

Cluster: no family and friend with the similar symptoms

 

個人病史：

[Personal History]-->

Occupation:Worker 

Education:college 

Marital status:single 

Exercise:no 

Alcohol:no 

Tobacco:no 

Coffee:no 

Tea:no 

Betel nut:no 

Drugs:Others 

Allergy:never ,藥物:NKA 

動物接觸史:無 

 

理學發現：

[Vital Sign]--> BH:166 cm BW:54.5 kg Temp:36.3 度C BP:125/71 mmHg

             PR:75 /min RR:17 /min

[General appearance]--> Consciousness:alert  GCS:(E4V5M6 ) 

Development:normal  Nourishment:well 

[Ear]--> EEC:clear  Hearing:normal  TM:intact 

[Throat]--> Tonsil:normal  Tongue:normal  Pharynx:normal  Mouth floor:normal 

[Nose]--> Discharge:no  Smelling:normal 

[Thyroid]--> Size:non-palpable  Nodule:non  Tender:- 

[Eye]--> Conjunctiva:not anemic  Sclera:not icteric 

Pupil size, R't:2mm  Pupil size, L't:2mm 

       Light reflex (R/L):+/+  Shape:regular 

[Lymph Node]--> Cervical:multiple  Axillary:non  palpable 

Inguinal:non  palpable  Consistency:soft 

[Ophthalmosopic]--> Ophthalmoscopic:no test 

[Neck]--> Neck:supple 

[Chest]--> Contour:normal  Percussion:reasonant 

Breathing sound:clear  Heart beat:regular 

         Heart sound:no murmur 

[Abdomen]--> Liver:non  palpable  Spleen:non  palpable  Mass:no  Tenderness:no 

             Bowel Sound:normal  Rigidity:non  Ascites:non  Distension:no 

             Hernia:normal 

[Genitalia]--> Genitalia:no test 

[Rectal]--> Anus:no test  DRE:no test 

[Spine & Extremities]--> Spine:left upper back tumor  Upper extremities:normal 

Lower extremities:normal  Nail:normal 

 

入院經過 :       

    According to the patient . A 42 -year-old female who has a history of Rheumatoid arthritis for years medication control . She suffered from left upper back mass note for one month .  In the beginning, she did not pay attention to it. However, the mass bigger than before . The associated symptoms were including loss 2kg in half year. shortness of breathing sometime . The symptoms persisted for one month, and aggravating ; therefore, admitted to ER. The followings are physical examination findings : patient is alert; has clear breathing sound, no icteric sclera, soft abdomen. Four extremities are muscle power 5/5 . The MRI received left posterior chest wall tumor (8.2*3.8*11.8 cm). D/D: soft tissue sarcoma,  metastasis, etc. Under the impression of left posterior chest wall tumor , she was admitted for further survey and treatment.