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
Review ofSystems Lab data Tentative
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
HistoryPersonal, Past,
& FamilyPresentillness
Physicalexamination
Review ofSystems Lab data Tentative
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
HistoryPersonal, Past,
& FamilyPresentillness
Physicalexamination
Review ofSystems Lab data Tentative
diagnosis
Review of systemCONSTITUTIONAL
HEENT
RESPIRATORYBREASTS
CARDIOVASCULARGASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETALNEUROLOGICAL
PSYCHIATRICSKIN
ENDOCRINE/METABOLISM
HEMATOLOGICALLERGIC AND IMMUNOLOGIC
Review of systemCONSTITUTIONAL
HEENT
RESPIRATORYBREASTS
CARDIOVASCULARGASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETALNEUROLOGICAL
PSYCHIATRICSKIN
ENDOCRINE/METABOLISM
HEMATOLOGICALLERGIC AND IMMUNOLOGIC
● 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.
Review of systemCONSTITUTIONAL
HEENT
RESPIRATORYBREASTS
CARDIOVASCULARGASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETALNEUROLOGICAL
PSYCHIATRICSKIN
ENDOCRINE/METABOLISM
HEMATOLOGICALLERGIC AND IMMUNOLOGIC
● 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
HistoryPersonal, Past,
& FamilyPresentillness
Physicalexamination
Review ofSystems Lab data Tentative
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
Laboratory data
Chiefproblem
HistoryPersonal, Past,
& FamilyPresentillness
Physicalexamination
Review ofSystems Lab data Tentative
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