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Brief introduction of patient’s condition

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posted on Jan, 29 2006 @ 08:22 AM
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Brief introduction of patient’s condition

Ms . Zheng who was a male patient with 42 years old entered the hospital on 17 Dec 2005 because post-lienectomy and occupying lesions in liver more in number and bigger in size for about more than three and a half years, then debilitation with both legs and waist-ache for three month.
Ms.Zheng felt left hypochondrail reign after taking food three and a half years ago. Then he went to hospital to be checked with CT scan . And the report showed that there were angeioma in spleen and small angeioma in liver.The pathology report showed tha angiocavemoma and bleeding in spleen while post lienectomy. However he entered hospital again because the angeiomas were much more in number and bigger in size once in CT scanning again. Interventional therapy with hemangiomas of liver was operated in southern hospital in March 2004.
Three months ago Ms.Zheng felt waist-ache persistently and could not tolerate without any inducemeng. And aches could be relieved while standing or sitting. Then he was checked again. There were muti-occupying lesions in liver while checked with B hypersound. and CT scan also showed that so many metastasizes in his liver, breast bone and right omoplata,. The immunohistochemistry reported that P53(-),ki67(-),CD31(+),cd34(+),VEGF(-),CD117(+)and Her-2(++).ECT showed nothing with bones. The results of doctors consultation with professors from Beijing and shanghai was spleen angiosarcoma and metastasis widely with liver and bones. Then a radiotherapy was underdone located with the fifth and sixth centrum. Thalidomide were intaken 150-250mg three times one day, and Avasting were dripped once every two weeks. Then Ms.Zheng feel that lumber and back pain was relieved obviously. After first radiotherapy, however, he found hypodynamia and anesthesiain both lower extremities. It is difficult for him to defecate and to turn the body over. After 20 times radiotherapy,200Gy every time in 20days,MRI showed that there were muti-metastasis in bone and stenosis in spine. Though dehydration therapy was given,his illness was not responsive to this treatment. In order to gai more better treatment, he was hospitalized in our department.
There was no hypertension, diabetes, hepatitis and tuberculousis in his medical record.
In physical examination, we found that there were no problem in encephalic nerves, heart, lung and Babinski sign. Infra-section of liver was located in under 4cm of costal margin.
Double knee jerk reflex and tendon reflex are hyporeflexia. muscle power in both upper extremities is V level ,in both lower extremities is III level. Deep sentation and superficial sentation decrease under sixth and seventh thoracic cord.
Admitting Diagnosis, hemangiosarcoma in spleen and muti-metastasis in liver and bone.
Admitting CT scan showed that mult-metastatic carcinoma with liver. Reports from the lab were that related substance with malignant tumor was 67.7U/ml; AFP 3.30UG/ml; CEA 0.74ug/ml;CA 199 10.67KU/ml and PSA 0.15ug/L. the therapeutic methods that Ms.Zheng were taken included dehydration protecting the function of liver promoting gastrointestinal motility and physical treatment. Then Ms.Could move with assistant by himself and did not feel lumbodorsal pain. However the state of Ms.Zheng’s illness was in progress gradually. And there was no effective measure to take to hold it back. So it is very thankful to you to offer a message if you have.




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