CasePresentation

內科intern吳易儒

Basic data

Name: 廖OO

Age: 47y/o

Gender: Male

Admission: 6.17/2014Education: Junior high school

Occupation:包工程水電行

Chart number: 41840334

Chief complaint

Hemoptysis for 2 days

Present illness

● This 47 y/o male with history of liver cirrhosis and HBV infection was admitted to our ER due to hemoptysis for 2 days.

● As the statement of him, he has followed up his liver disease in our OPD. But he lost followed up since 2011.

● Half a year ago, he would have been choked sometimes while drinking water. Bleeding after taking food and dysphagia were mentioned, too.

● About 2 weeks ago, a left submandibular mass was noted by him. Also, he complained about tarry stool.

Present illness

● nausea(-)● vomiting (-)● dizziness (-)● nosebleed(-)● dyspnea(-)● chest tightness(-)

● fever(-)● cold sweating(-)● abdominal pain(-)● cough(-)● dysuria(-)● anti-coagulant use

(-)

● He suffered from hemoptysis since 2 days ago. Therefore, he went to our ER.

Past medical history

Hospitalization: 2010.3.3 -3.152011.5.6 -5.142011.8.27 -9.5 GI bleeding-> Esophageal Varices s/p EVL

Personal history

Allergy: noneAlcohol: heavy drinkiner(維士比)Betal nut: yesCigarette: 0.5ppd for 20 yearsTravel history: deniedFamily history: Father had DM type II

Physical examinationGCS: E4M6V5 T/P/R: 37.7/104/25 BP: 101/68HEENTEyes-Conjunctiva: pale

-Cornea：yellowNeck-General：left neck big mass

Physical examination-Carotid pulses：regular , normal amplitude,

no bruits. -Jugular vein：no engorgement

Chest and Lungs-Inspection：normal thoracic cage, normal

expansion, no spider nevi.-Palpation：equal tactile fremitus.-Percussion：resonance to both lung field -Auscultation：clear

Physical examination

Heart-Inspection/palpation：PMI over the L't 5th

ICS mid-clavicular line, no LV heaves.-Auscultation：regular rhythm, normal S1,

loud S2, no S3, S4 or opening snap.

Abdomen-Inspection：no scars,no spider nevi, RUQ

superficial vein engorgement.

Physical examination

-Auscultation：normoactive bowel sounds , no bruits.

-Percussion：no shifting dullness . tympanic percussion

-Palpation：no tenderness ,no Murphy's sign, soft, no muscle guarding,no rebound tenderness, no mass.no hepatomegaly ,no splenomegaly

Hospital course-ER

Glucose AC AST PT INR aPTT

109 79 12.8 1.22 28.8

Hb HT WBC Seg Lymphocyte

9.0 27.4 3.4 79 13

BUN

10

Creatinine

0.6

ENT consultation 6/16 12:22ENT finding: Lt neck level II mass 2x2 cm, firm, non-movableLt parapharyngeal wall tumor with ulceration, no active bleedingA: oropharyngeal tumor r/o EV or GI bleeding Liver cirrhosisP: please trerat medical problem as your expertise 1. arrange PES 2. arrange neck CT or MRI with /without contrast including hypopharynx 3. ENT OPD f/u for further evaluation

CT report

● Evidence of bulky tumor involving left lateral oropharyngeal, hypopharyngeal and laryngeal walls. The origin is hard to defined.

● Enlarged lymph nodes are noted at submental area, left lateral retrophryngeal space and along left internal jugular chain, level II

Gastroscopy 2014/06/16 14:36:42

● Active bleeding in the left epiglottis. ● Suggest ENT for hemostasis and intubation

as needed for high risk of suffocation.

Laryngeal scope 2014/06/16 18:08:55

Left hypopharyngeal ca with ulceration and blood clot, no active bleeding Left vocal palsy Airway compromise【Diagnosis】 Left hypopharyngeal ca Suspected GI bleeding【Comment】 Protect airway Embolization if needed

Hospital course-ER ABG 60% PEEP 5

pH PaCO2 PaO2

7.553 28.3 178.8

SaO2

99.4%

HCO3 BE

24.3 3.1

Tentative diagnosis

● •Suspect left hypophargeal cancer with ulceration and active bleeding s/p endotracheal intubation for protect airway

● Anemia, related tumor bleeding● EV s/p ligation without active bleeding● Liver cirrhosis, child A● History of gastric ulcer

MICU Hospital course

● NG irrigation● Blood transfusion on 6/17-> Hb rise from 7.7 to 9.7● NPO● CVP for nutrition

Hb

6/1612:01

6/17 00:23

6/1709:06

6/1713:21

9.0 7.7 9.4 9.7

6/1717:49

6/1809:47

6/1814:32

6/1910:58

8.9 8.5 9.0 9.4

Gastroscopy 6/17 21:23pm

ESOPHAGUS1.One protruding mass with blood coating and friable

mucosal change at the left side of epiglottis are noted. Mild oozing is found. One pseudo-tract is noted below the right side of pyriform sinus (located upper of the esophageal opening).

2.Two varices (2F1, Cb, Li, RCS(-)) and one fibrotic ring are noted at the EC junction.STOMACH

1.Superficial Gastritis 2.Ulcer

Hb

6/1612:01

6/17 00:23

6/1709:06

6/1713:21

9.0 7.7 9.4 9.7

6/1717:49

6/1809:47

6/1814:32

6/1910:58

8.9 8.5 9.0 9.4

HT Albumin Total Bilirubin

Direct Bilirubin AST

29.3 2.7 2.7 1.0 72

Ammonia Glucose AC K P Ca Mg

131 120 3.3 1.6 7.7 1.3

MICU Hospital course

Chest echo: Left lung consolidationFever up to 38.2 degreeBlood culture: GPCArrange tracheotomy and biopsy to evaluate the neck mass

Medicine

● Esomeprazole for peptic ulcer● Glypressin for suspect GI bleeding● Metoclopramide for GI bleeding● Silymarin for liver cirrhosis● 6/18 T-piece ● 6/20 transfer to general ward.

Discussion

Neck mass

History taking

AGEPediatric(16-40)-inflammatory or congenitalAdult(>40)-neoplastic(tobacco/alcohol)

GROWTH PATTERNDuration-longer betterRapidly-infection/lymphomaFluctuate-viral/URI infection/congenital

SYMPTOMS Cervical meta-pain/hoarseness/dysphagia/otalgia

OTHER fever/BW loss/TOCC

Location

Physical examination

● Characteristicslocation, size, shape, consistency, tenderness, mobility, and color

● Oral Mucosa● Ear● Oropharyngeal● Skin● Cranial nerve● Thyroid gland● Abdomen

Labtory studies

● MostCBC

Infection/InflammationESR, CRP, Blood culture, EBV/CMV(adenopathy)

Specific serlogyT gondii, Bartonella, Tularemia, TB skin test

Bone marrow biopsyhematologic malignancy

Image study

● Ultrasoundguide fine needle aspiration● CTindentify primary sourcepossible vascular origin● MRIsoft tissue tissueperineural/CNS● PETdetect distant metastasisnot sensitive in neck mass

Diagnostic studies

● Fine needle aspiration(FNA)Cytology, Virus(EBV/HPV)

● Core biopsyUltrasound-guided/CT guided

● Excisional/incisional biopsyFrozen section analysis

Thanks for your attention

Hemoptysis

Airway obstruction