[Urology]

<<Pre-BMT>>
Personal history: nil
Family history: no related urological history
GU PE: no gross genital abnormality. No palpable scrotal mass or inguinal LAPs
DRE: smooth surface, elastic consistency and no hard nodule
Scrotal echo: bilateral grossly normal epididymis and testicles, no mass was found
Renal echo: Bilateral no hydronephrosis
GU cancer risk factors:
Denied family history of urological malignancy
Denied Chinese herb use (+) twice only
Denied cigarette use: (-)
Denied Hair dye: (-)

Denied Underground water: (-) live in 士林

[PM&R]

<< For 勞工保險失能診斷書..

Premorbid status:
no job for 1 year
need supervision in walking, walk without device at home, unsteady gait
need assistance in toilet and bathing
caregiver: wife

Brain MRI on 2017/4/10 : possible recurrent tumors

Admitted for IT chemotherapy

We are consulted for rehab program and 勞工保險失能診斷書.

A: clear
slow and blunted response
could follow orders consistently
oral feeding by himself
CN: impaired visual acuity of right eye
EOM: free
no facial palsy
tongue: midline
MMT: bilateral 5/5
 No spasticity
DTR:++/++
Sensory: symmetrically intact
FNF: No dysmetria
Functional status: independent in transfers (rolling, situp and standup but slow),
impaired sitting and standing balance
walk without device for short distance , poor dynamic balance, high risk of fall
ADL: partiailly dependent
mRS:3

[Ophthalmology]
CC: for Pre-BMT evaluation
Oph: op- trauma -
CVA: 1.0/1.0
Tp 15/15
Cornea clear in ou
A/C deep and clear ou
Lens clear ou
Fundus c/d 0.4 attached ou

[Neurology]
The neurologsit is consulted for pre-BMT evalaution.

NE:
con's: E4M6V5, oriented
EOM: full and free
pupil size: 7.5+/8+ (just after mydriatic agents for ophthalmological examiantion)
symmetric facial experssion, VF: intact by confrontation test, smooth saccade,
hypometric saccade +/+
no tongue deviation
motor: no pronator drift, 5/5 in general
DTR: ++/++ generally
Babinski sign -/-
FNF: no dysmetria
no dysadiadochokinesia
stepping test: intact

[ENT]
<<For Pre-BMT evaluation>>
PI: sore throat(+), odynophagia(+), otalgia(-), otorrhea(-), tinnitus(-), aural fullness(-),
hearing loss(-), vertigo(-), nasal congestion(-), rhinorrhea(-), post-nasal drip(-),
sputum(-), cough(-), facial pain(-), hyposmia(-), foul odor(-)
LF: bilateral intact ear drums, bilateral nasal cavity no mucopus, small ulcer over right
side soft palate and left side tongue base
H&N CT: mild left maxillary sinusitis

<<Sore pain>>
A 50 y/o male with intra-abdominal DLBCL was admitted for R-CHOP(I). After
admission, symptoms of abdominal fullness and jaundice improving after PTCD and
steroid use. He received rituximab on 3/16 and CHOP on 3/17. Sore throat
developped since 3/20. Right side tonsilitis was suspected and we added on
cefuroxime and mycostatin. However, persistent right side sore throat was still
mentioned after cefuroxime and mycostatin use. Physical examination revealed no
palpable lymphadenopathies. Due to above condition, we would like ask your further
expertise opinion for evaluation. Thank you very much!

A 50 y/o male had

1.intra-abdominal DLBCL was admitted for R-CHOP(I).
right sore throat was told for days
Fever(-) GERD(+)
Cough(-)
LF: mild injected arytenoid , no tonsillitis, no other laryngeal nor hypopharyngeal
lesions

--Chronic laryngiti
1. Antiacid agents
2. Transamin 1 # TID
3. Comfflam spray +/- oral NSAID
4. Thanks for consultation

[Psychi]
<< for Pre-BMT evaluation>>
[Assessment]

21 歲單身男性，與父母同住，目前為大同大學大四生。
No substance/alcohol/drug abuse or dependence
No past psychiatric diagnosis
No family history of psychiatric diagnosis
Previous medical compliance: fair

Family support system: fair (家人均了解病情，父母為主要照顧者，父親為可能捐

贈者)

性格特徵: 樂觀開朗

對移植之了解(包括危險性、副作用、抗排斥藥物之終身服用等): 部分瞭解，尚

未完全暸解過程細節，能接受風險。

[MSE]
Consciousness: alert and aware
Attention: fair
Attitude: cooperative
Affect: euthymic
Behavior: appropriate
Speech: relevant and coherent
Thought: denied suicidal ideation, no formal thought disorder, no delusions
Perception: no hallucinations
JOMAC: grossly intact
Drive: stationary appetite and sleep

[Nutrition]

照會主旨：for Pre-BMT evaluation

<Subjective>

1.前幾天喉嚨痛吃不太下，就改喝安素，不過液體食物喉嚨還是會不舒服

2.訪視時表示喉嚨疼痛感緩解，不過進食量還是只有平常的一半左右

3.今年初體重約 51kg 左右

4.大致了解化療飲食注意事項
<Objective>

Lab 2017/05/26:身高=168.0cm, 體重=49.9Kg, BMI=17.7 , 標準體重=55.9～68.3Kg,

尿素氮=14.7mg/dL, 肌酐酸=0.6mg/dL, 血色素=9.8g/dL, 白血球=1.8K/μL

Lab 2017/05/24:白蛋白=3.3g/dL

Estimated calorie/protein requirement= 1800-2100kcal/75-90g

照會主旨：A case of HLH, for diet education

1.衛教對象:病人與爸爸

2.目前院內餐可以全吃完,另外額外吃水果,蘋果(大)1 顆/次/天或寶吉小果汁 1 罐

/次

3.入院到現在體重下降 6-9 公斤,詢問牛肉/豬肉/起司/香蕉可以吃嗎?擔心自己吃

錯,很多食物不敢吃

4.住院前在成大念書,每天外食,重口味

5.之前院內飲食為低磷/低鉀/限水/隔離飲食,現在改為普通飲食

Lab 2017/04/07:身高=183.0cm, 體重=55.7Kg, BMI=16.6 , ALT(GPT)=207U/L, 尿素

氮=42.0mg/dL, 肌酐酸=1.1mg/dL, 血色素=8.4g/dL, 白血球=2.9K/μL

Goal calorie:2300-2600kcal/day
protein requirement:80-100g/day

Diet order:3/25-4/7 低磷/低鉀/限水/隔離飲食 限蛋白 45g

4/7~普通飲食

[Dentist]
This is a 58-year-old female for suspision of infection from dental origin.
Present dentition:
7654321, 1234567
7654321, 1234567
Crown prosthesis: Tooth 11, tooth 36
No sign of gingiva inflammation, very mild plaque deposition
No un-treated caries
Oral hygiene: fair to good
Panoramic X-ray showed: normal periodontal level, no bony pathology

[Oncology]
This 51 y/o female with history of
1. DM, most recent HbA1C=6.3%
2. Endometrial cancer, FIGO stage IB at least , status post Laparoscopic staging
surgery on
2015/4/22, para-aortic lympadenopathy status post CT guild biopsy on 2017/05/17,
metastatic carcinoma of gynecological origin

This time, the patient was admitted with progressive low abdominal pain for 1

year. She had regular visited Dr.童寶玲's OPD before.

Bilateral low abdominal pain had been noted since 2016/06. The character of pain
was persistent and cramping. The pain was exacerbated while lying down. Poor
appetite was noted. Body weigt loss from 76kg to 60kg in two years. Follow-up CA-
125 level was elevated from 21.0 U/mL(2015/07, post OP) to 50.8 /mL(2017/04/25).

The examination report were as following,

[Abdomen and pelvic CT]
a 3cm round mass, at infrarenal anterior aortocaval region, unknown nature,
suspect lymphadenopathy or primary malignancy.
[Chest CT]
1.small LUL nodule, 5mm.
2.likely pericardial cyst.
[EGD and colonoscopy]
no specific findings, only a 0.3cm tubular adenoma was found in T-colon
[Bone scan]
No definite osteoblastic bone metastasis noted.
[CT guild biopsy]
 Metastatic carcinoma of gynecological origin.

The Dr.林明燦 was consulted for laparoscopic biopsy. However,the GS doctor

adviced that contact Dr.梁博欽 for biopsy evaluation. The CT guild biopsy was done

smoothly. Biopsy datas revealed metastatic carcinoma of gynecological origin. The re-
staging chest CT was done on 2017/5/25.
The patient's pain is under medicaiton (Jurnista 1#QD + ultracet PRN) now. Anorexia
was noted since admission, and the PPN 1000ml per day is given for nutrition
support now. We are consulted for salvage radiotherapy.
Salvage RT is indicated. We had explained the procedure, benefit, and acute/late

toxicity of RT. Please arrange Dr. 黃昭源's clinic for follow up(腫瘤科星期四上午 10

診). Simulation will be arranged on 6/13 14:00. Treatment will start on 6/25 on LA3N.

Thank you for the consultation.

[Infection Disease]
44F,
#Pre-B ALL,relapse
#Multiple bony lesion, primary site unknown
#Bil. pleural effusion, susp. malignant pleural effusion
#Hypercalcemia

Underlying disease:
1. Pre-B lymphoblastic leukemia, s/p RIST URD PBSCT (D0 on
2014/9/24).
2. Bipolar disorder, followed in our clinic during 2010-2011

Admitted this time for multiple bony lesion, bil pleural effusion, and fever.
-persistent fever under levofloxacin(allergy to penicillin)
-shifted levofloxacin to tigecycline to cover CAP pathogen
-fever subsided

We are consulted for self-paid anti-fungal prophylaxis

Risk of IFD:
host factor: post-BMT, flank relapse now, s/p re-induction C/T
Evidence of active IFD:
-HRCT:1.Multiple osteolytic lesions.
2.Bilateral pleural effusion.
3.Small pericardial effusion
----no active lung lesion was found
-Aspergillus Ag:neg
-fever subsided under anti-bacterial agent, no cough
1.So far there is no strong evidence to support anti-fungal prophylaxis during
induction
chemotherapy in patients with ALL. But if the risk of invasive fungal infection is
considered very
high in this patient due to, for example, underlying co-morbidities or use of strong
chemotherapy,
antifungal prophylaxis(self-paid) can be considered after well explanation to the
patient about the
pros and cons of using posaconazole as antifungal prophylactic agent.
2. Please be aware that vincristine-containing regimen is contraindicated for patients
receiving posaconazole.
3.Please well-educate the patient regarding how to take the medication to
optimizeabsorption.
- 3 tablets QD
- Administer with food.
- Please swallow tablets whole. Do not divide, crush, or chew.
- Be aware that serum posaconazole level may be suboptimal if the patient develops
severe diarrhea
or vomiting.
4.Check drug steady-state level if necessary.
5.Please discontinue prophylaxis agent if ANC>500 or active fungal infection occurs.
6.Please be aware of occurrence of breakthrough IFD. Follow aspergillus Ag and CXR
when
necessary.
Thanks for your consultation. Please feel free to contact us if any additional
problem.

[Hematology]
50M
Right upper abdominal pain for two weeks with icteric skin/sclera and tea-color urine
Weight loss: 10 kg (74->64kg) in one year

Abdominal echo at 慈濟: A 10*13 tumor at upper abdomen

CT at 台安: hypovascular lesion arising from posterior to pancreatic head. Severely

compressed IVC.
=> To our GS OPD, then admission.
2017/03/06
Tumor biopsy: diffuse large B cell lymphoma
Microscopically, it shows diffuse permeation of atypical median to large-sized
lymphoid cell with single nucleoli and relative abundant cytoplasm.
Immunohistochemically, the atypical lymphoid cells are positive for CD20, CD10,
BCL6 and focal positive for MUM1 but negative for CD3. EBER in situ hybridization is
negative. A diffuse large B cell lymphoma is considered.

1. Arrange whole body CT (with/without contrast) for staging (head/neck + chest +

abdomen + pelvis)
2. Avoid tumor lysis: IV hydration with N/S + Feburic (cash) 0.5# QD PO
3. Check Alb, LDH, uric acid, K, Ca, P, PT/PTT, HBsAg, Anti-HBs, Anti-HBc, Anti-HCV,
Anti-HIV, EBV viral load
4. Rasburicase 0.15mg/kg once if uric acid > 10
5. Bone marrow study for staging: A+B
6. Record U/O for AKI
7. Monitor uric acid, BUN/Cre, K, Ca; correct electrolyte imbalance
8. Add Solu-medrol 40mg BID for lymphoma; beware of tumor lysis!
9. 14A transfer for further chemotherapy