1. Presented by Int. 楊為傑 Int. 吳建霆
Intern Seminar
Presented by Int. 楊為傑
Int. 吳建霆

2. Identification data Name: Mr. Huang Sex: male Age: 75 years old
Admission date: 2005/9/5
Chart number:

3. Chief complaint
Cough was noted for 7-8 years and was getting severe recently.

4. Present illness
Then he was transferred to NCKUH. Surgery was suggested, but he hesitated.
Had cough for 6-7 years.
Went to 衛生所 and took a CXR.
2004, Apr.
2004, Feb.
Transferred to 新樓，Took a Chest CT. He was told that he had thymoma
He was followed up at OPD.
Cough was getting severe since early 2005.
Dyspnea on exersion (+)

5. Present illness Patient accept surgery in middle 2005.
Had MRI on August, 2005.
Admitted on 2005/9/5

6. Present illness Cough (+), getting severe in recent 6 months.
Dyspnea on exertion (+)
No chest pain, no fever, no night sweat, no weight loss.
No muscle weakness

7. Past history No hypertension No DM Drug allergy history: neurotin
Alcohol(+), 20-30cc 藥酒 for several decades
smoking(+), half pack/day for 40+ years. quitted since 1996
No family history of malignancy

8. Physical examination Appearance: fair
Consciousness: clear
Appearance: fair
BT: 36.4C, P: 76 /min, R: 18 /min, BP: 132/74 mmHg
Activity: fair
Conjunctiva : not pale sclera: not icteric, no ptosis
Neck: supple, LAP(-)
Chest: symmetric expansion, subcostal retraction( - )
breathing sound: clear, no crackles
Heart: regular heart beat, no murmur
Abd: soft, not distended
Liver/ Spleen: impalpable / impalpable,
No tenderness, No rebounding pain BS:normoactive
Extremities: freely movable, pitting edema (+)grade I at lower extremities.
Skin:turgor fine, no rash

9. Lab data GOT GPT BUN Cr GLU BIL 17 15 1.1 108 Na K Ca P Cl CRP 147 4.4
9.2
3.4
3.61
WBC Hb
Plt
MCV
Hct
6.9K
12.9
205K 92
39.2%
Seg
Band
Lymph
Aty-Lym PT
APTT
76.7% -
14.4%
11.6
27.8

10. Lab data
CEA
CA199
CA125
CA153
SCC
4.868
5.4 27
5.1
0.17

11. Tentative diagnosis
Anterior mediastinal tumor, suspected thymic cancer.

12. Plan
Tumor excision.
Admitted to SICU after the operation.

13. OP finding

14. Remove CVP and Chest tube. Coarse breathing sound
No fever.
Wound pain
Coarse breathing sound.
Remove one chest tube
Remove CVP and Chest tube.
No discomfort was told.
extubation was performed smoothly in SICU
9/7
9/9
9/12
9/11
9/8
9/6
Stable vital signs.
Coarse breathing sound
Flatus passage(+)
Sputum(+)
Severe wound pain
Ambulation: good
Clear breathing sound.
MBD the next day.

15. Pathology report Pathologic diagnosis: Bronchial cyst.
Specimen : yellow fatty soft tissue, 7x5x3 cm
Many cystic spaces in a adipose tissue background.
The cystic spaces are mainly lined by ciliated columnar epithelium with foci of goblet cell differentiation.
A few thymic tissue can be identified.