limfoma.pptx

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