业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,1,般內科病例討論 2009-02-05,奇美PGY楊清傑 / VS鐘焜明,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,2,Basic data,Name:杜慶X Gender: male Age: 57 y/o Occupation: worker Bed number: 9003A Chart Number: 27248554 Date of admission: 98/02/01,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,3,Chief complaint,Abdominal intermittent dullness pain for 1 year and progressed in recent 2 weeks .,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,4,Present illness,Hepatitis B carrier for 30 years and took 保肝片 form local pharmacy. Surgical history: sciatic n. pain s/p many years ago. Suffered from abdominal intermittent dullness pain for 1 year. He came to local clinic for help and was told just gastric ulcer .Then he took some gastric medication home and felt better. But the intermittent pain was still persisted. Severe abdominal pain in recently two weeks. Fever and mild weakness was also noted. The pain pattern located in RUQ. Last for more than 30 mins. Intermittent. No radiation .No aggravate factor but relife in bed rest. In 斗六醫院, abdominal sonography showed one liver mass transffer to 台大雲林醫院 the same finding 屏東基督教醫院CT suspected liver abscess or tumor.,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,5,Present illness,At our ER No fever ,no cold sweating, no vomiting, no dyspnea, no chest pain, no dysuria, but malaise, poor appetite, abdominal dullness pain noted .CXR showed normal, no definite active lung lesion.Lab data showed W.B.C.12.9 with Segment82.5 ， CRP141.3 。 GOT142，GPT24 。Impression of fever suspected liver abscess and hepatic mass.Admitted on 98/02/01 for further evaluation and management.,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,6,Past Medical History,1.Previous disease:HTN(-),DM(-) ,CAD(-),HBV carrier for 30+ years. 2. Drug allergy: No known allergy. 3. Usual medication: 保肝片,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,7,Personal History,Smoking: 1 ppd for 3040 years Drinking: one glass of 洋酒/day Betel nuts use: quit for 30+ years. History of oversea travel: denied History of contact with animals or sick people: denied .,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,8,Family History,Diabetes Mellitus (-) Hypertension (-) Heart disease (-) HBV disease (+) Cancer history (-),业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,9,Physical Examination,General: acute ill-looking, weakness. Vital sign : T/P/R = 36.2/114/20 , BP = 124/60 HEENT: pale conjunctiva(-), anicteric sclera(-) Chest :bilateral air entry (+), breathing sounds :clear Heart: RHB without murmur, S1()；S2()；S3()； S4() Abdomen: Soft, flat, no distension, adnominal pain over RUQ, murphy sign(-), mass (-),wound or op scar(-) Extremities: freely movable , pitting edema(-) , bed sores(-), rash(-),业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,10,Lab data,WBC: 12900 PT/ aPPT : 12.7 /28.9 Seq: 82.5 % INR: 1.2 RBC: 4.00 Hgb: 12.8 MCV: 93 % CRP: 141.3Platelet : 143,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,11,Lab data,SMA: Glucose:146 BUN: 15Cr: 0.7Na:126 K:3.88GOT: 142 GPT:24Albumin：3.1，Bili Total：1.18,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,12,Image study,CXR,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,13,Tentative diagnosis,1.Fever suspected liver abscess 2.Liver mass , cancer or abscess? 3.HBV carrier.,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,14,Admission course,Admission on 98/02/01 Panadol 1# QID poMorphine 4mg prn imFlumarin 1gm q12h ivN/S 40cc q1h iv,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,15,Admission course,Abdominal sonography on 02/02 Liver: The echogenicity was coarse. The size was normal. The surface wassmooth. One huge mass(6cm) with scattered calicified spots at Lt lobe and involving to Rt lobe.Portal vein: Thrombosis of Lt portal vein.Intrahepatic duct: Mild dilatation of Lt IHD. Diagnosis:1. Parenchymal liver disease2. Hepatic tumor, R/O Cholangiocarcinoma or HCC3. Lt IHD dilatation4. Lt portal vein thrombosis,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,16,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,17,Admission course,98/02/03 Lab data CEA：8.51CA199： 1119Anti-HCV(-)HBsAg(+)AFP： pending,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,18,Admission course,98/02/04 Abx change to Zinacef 750mg q8h iv CT of the abdomen There is an inhomogeneous hypodense tumor, about 10x9x6cm in dimensions in the left lobe. The proximal intrahepatic ducts are dilated.IMP: 1. Intrahepatic cholangiocarcinoma in the left lobe.2. Metastatic paraaortic LNP, cephadal to the left renal vein.,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,19,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,20,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,21,Admission course,ConsultGS for surgical evaluation.,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,22,Thank you for your listening,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,23,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,24,业精于勤荒于嬉 行成于思毁于随 【医学生物PPT，欢迎收藏分享】豆丁网友,25,