limfoma.pptx
TRANSCRIPT
MORNING REPORTdr. Vina - IPD
Tuesday, 26th November 2013
PHYSICIAN IN CHARGE:
I A : dr. Vina, dr Retty, dr. Fitranti (cardio)I B: dr. Zoraida, dr. EvaII : dr. Budi H.III : dr. Atma Gunawan Sp.PD-KGH
MODERATOR : dr. Supriono, Sp.PD-KGEH
Summary of Data Base
Male/ 57 y.0/ w. 27
Chief complain: general weakness
Patient suffered from general weakness since 2 years before admission,
worsened in the last 2 weeks. He complained decreased of body weight, but he didn’t
know exactly the number of diminished bodyweight. He also couldn’t walk further
without assistance.
Patient also suffered from abdominal bloating since 2011, his abdomen
became larger in last 1 year, had performed abdominal USG, Abdominal CT Scan, and
biopsy and diagnosed with lymphoma maligna, but the result was lost. He had
abdominal operation in July 2011 in RST hospital. The doctor said that tumor has
spread around all of his stomach. And then patient was reffered to RSSA
He didn’t complained abdominal pain, nausea nor vomitting. His passing
urine was normal, yellowish with frequency 5-6x/day. He felt desperate with this
condition so that he decided to do alternative medication until now.
Summary of Data Base
He eats normally, 3 times/day and 5-7 spoons each. He drinks about 1 litres/day.
Patient also complained about chronic cough since 3 years ago, produce
white sputum without blood. He had no history of fever.
Past Medical History :
History of Hypertension and Diabetes were denied.
Family History :
History Cancer, Hypertension and Diabetes on family were denied.
Social History :
Patient used to smoke 1 bar/day since youth. He has been married, and has 2
children. He works as a farmer.
Physical examinationBP = 110/70mmHg PR = 80 bpm, strong, and regular
RR = 28 tpm, tachypneu
Tax = 35 °C
General appearance looked severely ill GCS 456 Look underweight
Head Anemic (+) Icteric (-)
Neck JVP R + 4 cmH2O; 45°Vena dilatation (+)
Axilla D/S lympadenopathy +
Thorax: Cor: Ictus invisible and palpable at ICS V MCL SinistraLHM: MCL, heart waist (+)RHM: SLS1 S2 single, no murmur
Lung: Stem fremitus D < S , dullness at lower area lung D, decrease of breath sound at right lung, rh - -, wh - - s s + - - - d s + + - - d s
Abdomen distended, sicatric post op laparotomy, bowel sound normal, Liver span hard to evaluate, Traube space dullness +, hackett 3 undulation +, lympadenopathy inguinal S
Extremities No edema, warm acral
Laboratory findingLab Value Lab Value
Leukocyte
Hemoglobin
9270
9,90
3.500-10.000/µL
11,0-16,5 g/dl
NatriumKaliumChloride
1344.07105
136-145 mmol / L3,5-5,0 mmol / L98-106 mmol/L
MCVMCH
82.5026.30
80-9726.5-33.5
RBG 96 Mg/dL
PCV 31,10 35-50% SGOT 23 11-41U/L
Trombocyte 222.000 150.000-390.000/µL
SGPT 7 10-41U/L
Ureum 19,10 10-50 mg/dL Albumin 3.65 3,5-5,5 g/dL
Creatinine 0.53 0,7-1,5 mg/dL LDH Waiting for confirmation
ECG (Nov 25th 2013)
• Sinus rythm, heart rate 84 bpm• Frontal Axis : normal• Horizontal Axis : CCWR• PR interval : 0.16”• QRS complex : 0.08”• QT interval : 0.32”• Conclusion : Sinus rythm, heart rate 84 bpm
Abdominal usg July, 18 2011
• Mass in suprapubic area diameter 10,9cm x 11,1 cm
• Portal vein diameter 1,1cm (normal portal vein 7-15 mm)
CXR (25/11/2013)• AP position, asymetric, less inspiration, enough KV• Trachea in the middle• Soft tissue: thin ; bone: normal• Mediastinum : radioopaque appearance • right phrenico-costalis angle is blunt, with meniscus sign +, and the left
phrenico-costalis angle is blunt• right hemidiaphragm is covered by radioopaque shadow, the left is
dome shaped• Lung : thick fibroinfiltrate, radioopaque appearance with sharp border
in basal right lung, increased BVP in right lung. • Cor site, size, and shape look normal
Conclusion: right pleural effusion, suspect mass in mediastinum dd mass lung D, susp lung TB
CUE AND CLUE PL IDx PDx PTx PMo
Male / 45 yoAxGeneral weakness since 2 years, worsened in last 2 weeks, abdominal enlargment, multiple lymphadenopathy
Hb : 9,90MCV : 82,50MCH : 26,30
1. General weakness
1.1 due to anemia 1.2 due to malignancy
Bed RestTreat underlying diseaseHCHP diet 2100 kcal/day, low salt 1gr/kgbw/day
Subj
CUE AND CLUE PL IDx PDx PTx PMo
Male/45 yo
Referred from internis with lymphoma hodgkinAbdominal enlargement, bloating sensationLymphadenopathy in axilla D/S and inguinal S
PE :Multiple lymphadenopathy
CXR : pleural effusion D
Leucocyte 9.270Limphocyte 24,8
2. Multiple lymphadenopathy
2.1 Lymphoma Maligna2.1.1 Hodgkin stg IVB, karnofsky score 302.1.2 Non hodgkin
2.2 metastatic process
FNAB Confim stagingPlan to ChemotherapyABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) waiting for FNAB result
SubjVSLDH,Uric acid, serum electrolyte
CUE AND CLUE PL IDx PDx PTx PMo
Male/45 yoGeneralized weakness, abdominal enlargement, multiple lympadenopathy
PEConjungtival anemic,
Hb : 9,90MCV : 82,50MCH : 26,30
3.Anemia Normochrom-normositic
3.1.dt of chronic disease (malignancy)3.2 Fe deficiency
Reticulocyte countSI, TIBC
Confirm diagnosePRC transfussion 1 pack/day until Hb > 10gr/dl
Hb, transfussion reaction, volume overload
Male/45 yoAxBloating sensation, abdominal enlargment in last 1 year, chronic cough
Multiple lymphadenopathy
PELab•Alb: 3.65
4.Ascites Permagna 4.1 peritoneal lymphomatosis
4.2 malignancy related ascites
4.3 tuberculous peritonitis
Analysis, cytology and culture ascitic fluid
SAAG
Abdominal CT Scan
High calorie high protein diet 2100 kcal/day Furosemide 1x40 mgSpironolactone 1x100
Evacuation ascitic fluid 2L/day
SubjectiveAlb, VS post evacuation
CUE AND CLUE PL IDx PDx PTx PMo
Male/45 yoAxBreathlesness gradually became worsen, chronic cough since 3 years, decreased of body weight,
PERR 28 tpm Tactile fremitus D<SPercussion dullness at basal right lungAusc absence of breath sound at right lungLab•Breath sound decrease at right lung•CXR : pleural effusion D
5.Pleural effusion dextra
5.1 primary effusion lymphoma
5.1.due to metastatic process to the lung
5.2. due to mediastinum mass
5.3 lung cancer
CT scan thorax
Analysis, cytology and culture pleural effusion fluid
NSE (neuron spesific enolase)
•Evacuate pleural effusion with USG thorax guiding
•02 2-4 lpm NC
•Consult pulmonology dept
Subjective
CUE AND CLUE PL IDx PDx PTx PMo
Male/45 yoAxchronic cough since 3 years, with whitish sputum, no blood, decreased of body weight,
PERR 28 tpm Tactile fremitus D<SPercussion dullness at basal right lungAusc absence of breath sound at right lungLab•Breath sound decrease at right lung•CXR : pleural effusion D
6. Lung infection
6.1 Lung TB6.2 Metastase process in lung
Sputum culture and sensitivity test
AFB sputum
Wait for confirmationC pulmonology dept
Subjective
Problem Analysis
Lung cancer (?)
Lymphoma maligna
Pleural effusion
Anemia
Ascites permagna
General weakness
Risk Factor AnalysisLymphoma Maligna :1. Immunocompromised state2. Older Age3. Exposed to certain pesticides and ionizing radiation4. Viral infection : AIDS, Retrovirus, EBV
Management Analysis
• Emergency : • Urgency :• Non urgency :Bed rest02 2-4 lpm NCHCHP diet 2100 kcal/dayAscitic fluid evacuationPRC transfusion 1 pack/day until Hb > 10 gr/dlPlan to chemoteraphy, waiting for confirmed diagnosed
Condition this morning
S : weaknessBP : 110/70 mmhgPR : 76x/mntRR : 24x/mntTax : 36
Thank you