血液腫瘤科標準病歷範本-Admission Note
Case 1: Malignant lymphoma
Chief complaint：
Progressine enlargement of ncck lymph node for 2 weeks.
Present illness：
This 25 years old healthy university student noticed a nodular mass over the right neck 2 weeks ago, paidlittle attention to itincipiently, envisioned thegranularly enlarged right neck mass roughly 3cm, and visited our ENT OPD one week ago. The ENT initially indicated no mass over the nasopharynx or oropharynx. The lymph node excisional biopsy displayed diffuse large B cell lymphoma. Throughout the complete course, there was no chillness, fever, or body weight loss. He was transferred to our hematology OPD and admitted for further staging and treatment.
Impression
Malignant lymphoma, diffuse large B cell type. Stage to be determined.
Plan
- Diagnostic plan：Bone marrow expiration and biopsy, check LDH, HBsAg, Anti-HCV, Biochemistry, CBC, Chest CT Scan, Abdominal CT Scan, Gallium scan.
- Therapeutic plan：Chemotherapy with R-CEOP.
Educational plan：Discussion with patient and family, about the diagnosis, stage, therapeutic plan, side effect and complication of chemotherapy, prognosis.
Case 2:Acute leukemia
Chief complaint：
Gum bleeding for 2 days.
Present illness：
This 40-year-old woman was well until she was easily fatigued in recent weeks.
She visited local clinics 2 weeks ago; biochemically, the liver was within normal limits. Her exertional dyspnea happened one week ago; so did her gum bleeding during tooth brushing in recent 2 days. In our hematology OPD, the symptoms were anemia-associated; the petechia occurred over the legs.
Besides, the CBC data discovered: Hgb 8 gm/dl; WBC 16,000/cumm with 20% blast cells; platelet 18,000/cumm. Acute leukemia was highly considered. Sequently, she was admitted for further evaluation and treatment. Throughout the complete course, there was no chillness, fever, headache or vomiting.
Impression
Acute leukemia, cell type undetermined.
Plan
- Diagnostic plan：Bone marrow aspiration and biopsy.
Chromosome study.
Flow-cytometry study of bone marrow cell,
CBC, Differential count of white blood cells,
PT, APTT, fibrinogen
- Therapeutic plan：induction chemotherapy.
Educational plan：Discussion with patient and family about the diagnosis, therapeutic plan, side effect and complication of chemotherapy, prognosis.
Case 3：Metastatic cancer of unknown origin
Chief complaint：
Low back pain for weeks.
Present illness：
This 52-year-old man, a known case of metastatic bone carcinoma of unknown origin, commenced with low back pain for weeks and hemiparesis for days and received serial examinations containing L spine MRI and bone scan which revealed L3 metastasis laminectomy on June 19, 2010. Pathologically, metastatic carcinoma was certified; the origin, unknown. Ensuantly, he was admitted for further evaluation and radiotherapy.
Impression
Metastatic bony carcinoma of unknown origin.
Plan
-Diagnostic plan：
1、check PSA, CEA, CA-199.
2、Arrange Chest CT to rule out lung cancer.
-Therapeutic plan：
3、Consult RTO for local R/T.
4、Add Narcotic drug for pain control.
-Educational plan：
預防跌倒。
Case 4: Bladder TCC
Chief complaint：
Gross hematuria for 2 months.
Present illness：
This 70-year-old man of antecedent hypertension under our hospital’s regular control had gross hematuria for 2 months before visiting our urology outpatient clinic where physicalexamination expressed a soft abdomen without tenderness, knocking pain, and palpable mass. His TUR-BT on 05/08/2010 manifested bladder urothelial carcinoma-invaded muscle wall; hence, he was suggested for further evaluation.
Impression
Bladder urothetal carcinoma
Plan
- Diagnostic plan：
1、Abdominal CT or Abdominal MRI.
2、Bone Scan.
- Therapeutic plan：
1、Consult CV, Chest for pre-OP evaluation.
- Educational plan：
討論術後可能須做neobladder, 或加上adjuvant C/T。