1. Case Discussion
Intern 蘇熙淵

2. Name: 陳X珊
Gender: female
Age: 19
Admission Date: 95/8/30
95/9/25

3. Chief Complaint
For CXR multiple bilateral reticular patches surveys

4. Spontaneous pneumothorax
Present illness
Sudden onset SOB
奇美ER—
Spontaneous pneumothorax
Chest tube
f/u CXR
Multiple reticular patch bil lung
NCKUH ER
Chest discomfort
SOB(+), DOE(+)
95/06
95/8/23
95/8/30
Chest tightness , cold sweating, radiation, orthopnea, PND
cough, sputum, hemoptysis,
generally weakness, poor appetite and BWL

5. Past History G3P0AA2, GA 10+ weeks HTN (-) DM (-) Asthma (-)
Pneumothorax history: denied
NKDA
Smoking (-) Drinking (-)Betel nut (-)

6. Physical Examination Chest Heart No Heaves and thrill.
T/P/R: 37/ 84/ ;BP: 101/ 65
Chest
Symmetric expansion, no retraction, accessory muscle use(-)
Breathing sounds: wheezing (-), crackle (-),
Right side: chest tube wound pain
Heart No Heaves and thrill.

7. Lab Data

8. 生化檢驗報告: 95/08/30 CREA L 0.5 mg/dl 0.7-1.2 GOT 25 U/L 0-40
BUN mg/dl
NA mmol/L
K mmol/L
GPT U/L
GLU.P.C. H 124 mg/dl

9. 血液檢驗報告:95/08/30 WBC H 11.1 K/cmm 3.2-9.2 APTT(NP) 29.20 secs
RBC M/cmm
Hb g/dl
Hct %
MCV fl
MCH pg
MCHC g/dl
RDW %
Pl H 386 K/cmm
PT secs
PT(NP) secs
APTT secs
APTT(NP) secs
Blast %
Pro %
Myelo %
Meta %
Band %
Seg H 79.1 %
Eos %
Baso %
Mono %
Lymph L 13.1 %
Aty-lym - %

10. ABG(95/08/30) PH 7.442 7.35-7.45 PO2 L 73 mmHg 75-100 TCO2 23.7 mmol/L
BEecf mmol/L
%sO2c %
PCO2 L 32.8 mmHg
HCO mmol/L
BEb mmol/L
SBC mmol/L

11. PRED BEST %PRED BEST %PRED
PFT 95/09/01
PRED BEST %PRED BEST %PRED
FVC
FEV
FEV1%
MVV
TLC RV
DLCO
mild restrictive ventilatory defect
severe impairment diffusion capacity

12. 95/09/14 95/09/15 RF <20.0 IU 0-20 ANA * 1: 40(+-)
Anti-nDNA 1: 10(-)
SSA/SSB Ab
SS- A Ab Negative
SS- B Ab Negative
Anti-ENA screening Negative

13. Imaging Study(8/23)

14. Imaging Study(8/29)
Bilateral Reticular patch

15. CT(9/19)

16. Differential diagnosis
Alveolar proteinosis
Interstitial pneumonitis
Crypyogenic organizing pneumonia
ARDS
lymphangioleiomyomatosis

17. Diagnosis
Multiple bilateral reticular patches, suspect lymphangioleiomyomatosis (LAM)

18. Chest Ward (8/30~9/2)
DxMultiple bilateral reticular patches, suspect lymphangioleiomyomatosis (LAM)?
PFT
CS: thoracoscopy biopsy, CT
OBS-GYN
Abdominal echo
ANA / RF
9/2MBD OPD for termination

19. 9/11 suction D&C (GA 12+ wks) 9/25 CS OPD
Pulmonary alveolar proteinosis
Arrange 10/23 admission, 10/24 OP

20. OP Note:
Diffuse alveolar disease, susp proteinosis
VATS wedge resection of RLL

21. Pathology(10/24) Alveolar proteinosis PATHOLOGIC DIAGNOSIS:
MICROSCOPIC FINDING:
Section shows lung parenchyma with accumulation of an
amorphous eosinophilic PAS-positive material in the
alveolar lumina. Small lymphoid aggregation in the
interstitium and some proliferation and desquamation of
pneumocytes are also noted. There is no evidence of
malignancy.   

22. Discussion