case presentation -group-14--20160520

Case presentationGroup 14

2016.05.20

Chiefproblem

HistoryPersonal, Past,

& FamilyPresentillness

Physicalexamination

Review ofSystems Lab data Tentative

diagnosis

Chief problem

A 71-year-old man had gross hematuria and a mass in the bladder

Chiefproblem

HistoryPersonal, Past

& Family

Presentillness

Physicalexamination


diagnosis

Personal history• He was married, had adult children, • retired from the shipping industry, • where he had been exposed to

asbestos. • He was physically active in outdoor

activities.

Past history

Erectiledysfunction

Hypertrophiccardiomyopathy

DiverticulosisObstructivesleep apnea

Nephrolithiasis(had treated)

HypertensionHyperlipidemia

Past history• Results of a colonoscopy

performed 1 year earlier were normal.

• Medications included atorvastatin and verapamil ; other medications had recently been stopped.

• other medications : doxazosin, amlodipine, valsartan, telmisartan, hydrochlorothiazide, potassium aminobenzoic acid, oxybutynin chloride, and potassium chloride supplement

• NO smoke & NO alcohol

Family history

There was no family history of urologic

cancers.

Chiefproblem



Physicalexamination


diagnosis

Transurethral resection of the prostate :because of lowerurinary tract symptoms and urinary retention. Pathological examination of the tissue reportedly had shown an area of focal high-grade prostate intraepithelial neoplasia.

prostatic biopsies : negative .Four subsequent prostatic biopsies, the most recent performed 4 years before

Results of a colonoscopy were normal

12 years ago

4 years ago

Present illness

1 year ago

gross hematuria(血尿 ) and a mass in the bladder for 6 weeks

painless hematuria had developed, with passage of clots

prostate-specific antigen (PSA):13.0 ng per milliliteCT :After 2 days,computed tomography (CT) reportedly revealed a multilobulated(多房性 ) mass (isodense to hyperdense and measuring 8 cm by 7.5 cm by 6.5 cm) in the urinary bladder, diffuse fat stranding in the perivesical and left periurethral regions, and bilateral intrarenal calculi(結石 ) and cysts

cystoscopic examination:The next day, cystoscopic examination revealed an open prostatic urethra and brisk(輕微 ) bleeding. A fungating lesion at the anterior bladder neck at the 12 o’clock position, with an adherent clot, was partially excised. Pathological examination of the tissue reportedly showed focal adenocarcinoma in situ

Two mons

ago

3weeks ago

Present illness

1 mon ago

Ultrasonography of the abdomen and pelvis revealed bilateral renal cysts and bilateral nonobstructing nephrolithiasis

The next day, repeat cystoscopy reportedly revealed a large fungating lesion and clot at the anterior bladder neck at the 12 o’clock position. Flushing of the bladder and biopsies were performed. Pathological examination of the biopsy specimens reportedly showed adenocarcinoma; consultation with outside experts was pending. CT of the abdomen, performed the next day, reportedly revealed no evidence of metastatic disease. After decompression of the bladder with a catheter(導管 ), irregular thickening of the bladder wall was seen, with an irregular, multiloculated gas collection, 2.5 cm by 3.5 cm, in the suprapubic(恥骨 ) region.

2 weeks ago

Present illness

Transrectal biopsies of the prostate with ultrasonographic guidance: adenocarcinoma in one of two cores from the right base, with a Gleason score of 7 (grade 3 plus grade 4) on a scale of 1 to 10 (with higher scores indicating a worse prognosis), involving 30% of the tissue, and adenocarcinoma in a core from the left lateral midportion, with a Gleason score of 6 (3+3), involving 10% of the tissue.

Present illness5 days after

2nd cystoscopy

the pulse was 50 beats/min and the blood pressure, temperature, respiratory rate, and oxygen saturation were normal.

Rectal examination was not performed, and the remainder of the examination was normal.Blood examination

K+ 3.3mmol/L(3.3-4.8)creationine 1.3mg/dL(0.6-1.5)

Urea nitrogen 15mg/dL(8-25)eGFR 59 ml/min/1.74m2 (>=60)

The complete blood count and levels of other electrolytes, calcium, and glucose were normal.

Present illnessThis

evaluation

Chiefproblem



Physicalexamination


diagnosis

Review of systemCONSTITUTIONAL

HEENT

RESPIRATORYBREASTS

CARDIOVASCULARGASTROINTESTINAL

GENITOURINARY

MUSCULOSKELETALNEUROLOGICAL

PSYCHIATRICSKIN

ENDOCRINE/METABOLISM

HEMATOLOGICALLERGIC AND IMMUNOLOGIC


HEENT

RESPIRATORYBREASTS


GENITOURINARY


PSYCHIATRICSKIN



● No night sweats. No fatigue, malaise, lethargy. No fever or chills.● Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis. No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.● No breast pain, soreness, lumps, or discharge.● Mild obstructive sleep apnea No cough. No wheeze. No hemoptysis. No shortness of breath.● Hypertrophic cardiomyopathy, hypertension● Diverticulosis No abdominal pain. No nausea or vomiting. No diarrhea or constipation. No hematemesis. No hematochezia. No melena.● Hyperlipidemia No unexplained weight loss. No polydipsia. No polyuria. No polyphagia.


HEENT

RESPIRATORYBREASTS


GENITOURINARY


PSYCHIATRICSKIN



● No musculoskeletal pain. No joint swelling. No arthritis.

● He had an episode of mild confusion. He has chronic right hemiplegia. No headache

or neck pain. No syncope or seizure.● He gets occasionally confused.

● No rashes. No lesions. No wounds.

● No urgency. No frequency. No dysuria. hematuria. Lower urinary tract symptoms,

urinary retention. Erectile dysfunction, nephrolithiasis No discharge. No pain. No

significant abnormal bleeding● No anemia. No purpura. No petechiae.

No prolonged or excessive bleeding● No pruritus. No swelling.

Physical examination• PE by Dr. Donald S. Kaufman

– HR: 50/min, blood pressure, temperature, respiratory rate, and oxygen saturation were normal. BMI: 30

– Rectal examination was not performed• PE by Dr. Olumi

– Digital rectal examination: the rectal tone was intact, the pelvic organs were mobile, the prostate weight was estimated to be 40 to 50 g, and there was no palpable prostate nodule or rectal mass.

admission

Chiefproblem



Physicalexamination


diagnosis

Laboratory data

• CBC and other electrolytes, calcium, and glucose； Cr、 urea nitrogen were normal

Abnormalblood potassium 3.3 mmol (3.4-4.8)

eGFR 59 ( ≧60)

Laboratory data

Chiefproblem



Physicalexamination


diagnosis

Tentative diagnosis Urothelial carcinoma of the bladder neck, the prostatic urethra, or both.But after Immunohistochemical staining

P63 - PSA +

Division of workYao Chung-hsia

Yu Hung-Chun, Li jia-xuan, Li ho

Lee Yi-zhang

Wu Zon-han

Chan Po-Kai

Thank you for your attention

case presentation -group-14--20160520

Health & Medicine