張貼日期：2017/8/23 上午 02:54:43
A 69 y/o F
[Major past history]
1. HBV carrier
2. HTN
[History summary & assessments]
The patient had increased vaginal discharge was noted since mid April, 2018. Weight loss(?), diaphoresis(?),
She underwent radical hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymph nodes dissection on 2018/05/08. The pathology report showed DLBCL. We were consulted for further evaluation.
[PE] (待訪視)
GCS: E4V5M6
HEENT
Head: trauma (-), scar(-)
Eye& Ear: pale conjunctiva (-), icteric sclera (-)
Mouth: petechiae(-), thrush(-)
Neck: supple, lymph adenopathy (-), jugular vein engorgement(-)
Axillary lymph nodes (-)
Chest
Inspection: symmetric expansion, Accessory muscle exertion(-)
Auscultation: bilateral clear, wheezing(-)
Abdomen
Inspection: soft, globular, caput medusa(-), petechiae(-)
Auscultation: bowel sound(hypo-active)
Palpation: peritoneal sign(-), tenderness(-), hepatomegaly(-), splenomegaly(-), mass(-)
Percussion: normo-tympanic, No shifting dullness
Limbs: cold, edema(-), decreased arterial pulsation(-)
Skin: Skin turgor fine, petechiae(-), ecchymosis(-)
[Hemograms]
7/19 WBC(5.98 K/μL) HB(15.5 g/dL) PLT(258 K/μL)
5/14 Differential count: no abnormal cells
[Biochemistry]
7/21 Bil-T(0.74), CRE(0.7 mg/dL), LDH(462 U/L), Uric acid(? mg/dL)
1. Please check following tests at next blood sampling
- Serum LDH, uric acid, IgA, IgG, IgM, SPEP, Beta-2 microglobulin.
2. If formal patholgy report confirmed lymphoma, please complete following lymphoma staging:
- Check HBsAg, Anti-HBs, Anti-HBc, Anti-HCV, EBV viral load, HIV Ag/Ab Combo-for screening, G-6-PD
- Arrange neck + chest + abdomen + pelvis CT(+/-C) (optional：跟PET擇一)
- Arrange PET scan. (optional)
- Arrange cardiac echo as pre-chemotherapy evaluation. (if Age > 65 y/o)
- Check Anti-HTLV I/II (if T cell lymphoma)
- Check Alb, ESR (if Hodgkin lymphoma)
- Check HHV-8 (if primary effusion lymphoma)
- Contact us for BM study (項目: A+B; +C & F if cytopenia is present)
3. BM study will be arranged soon
- 請簽署：
(1)骨髓檢查同意書
(2)剩餘組織臘塊同意書
(已確定為淋巴瘤的病人不用簽署剩餘檢體同意書)
- 請開立下列骨髓檢查醫令，並填好"病理"及"染色體"紙本委託單
1. TRE00009 Bone marrow aspiration and biopsy → Aspiration+biopsy記帳醫令
2. 08128B0P Bone marrow smear and Differentiation Count → BM smear醫令
3. 25004C0W Surgical pathology Level IV -> Biopsy醫令
4. 25007BZW Cytogenetics (hemopoietic disorder) → Cytogenetics醫令 (若CBC異常才驗)
5. 12206B0P Surface marker (immunophenotyping) for leukemia and lymphoma → 血液室Flow醫令 (若CBC異常才驗)
- Contact us if above documents are available
Thanks for your consultation. Contact us if any problems