20190131_IMRH case presentation_陳佳菁_V.4_Public
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A Case Presentation Framework with Problem-Oriented Analysis; IMRH case with interstitial lung disease confirmed by HRCT and suspected tRNA synthetase syndrome c/w secondary Sjogren's syndrome
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20190131_IMRH case presentation_陳佳菁_V.4_Public
- 1. 實習醫學生｜陳佳菁 指導老師｜陳彥如醫師 指導老師｜謝佳偉醫師 | 2019 . 01 . 31 VGHTC_IMRH Case Presentation
- 2. A 64-yr woman suffered from Persistent Dry Cough with Progressive DOE for 3 months
- 3. 陳 女 士 病歷號隱匿 64 years old 1 2 3 4 5 Patient Profile Chief Complaint History of Present Illness General Info 64-year-old Woman Independent ADL Occupation Former Shopkeeper of Izakaya @Tokyo Substance Use No Alcohol, Tobacco, Betel Nut Education Senior High School Socio-economy Widowed, Good Economic Status Second-Hand Smoking for 30 years Admission Day - 2019/01/20
- 4. Persistent Dry Cough with Progressive DOE for 3 months Patient Profile Chief Complaint History of Present Illness
- 5. How the Serial Events Initiated ? 1 Son, Daughter-in-Law, Grandchildren - Fever . Cough Mycoplasma Pneumonia * Only 1 Episode of Fever AUG. 2018 CLUSTER EVENT 3 OCT. 2018 PROGRESSIVE DYSPNEA 2 VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness
- 6. How the Serial Events Initiated ? 1 Son, Grandchildren - Fever . Cough Mycoplasma Pneumonia Family Well-Treatment and Recovery *Fever up to 39’C for 4 hours AUG. 2018 CLUSTER EVENT 32 Family Members were Disease-Free While Prolonged Cough Persisted NYHA Functional Class II SEP. 2018 INTRACTABLE COUGH VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness
- 7. How the Serial Events Initiated ? 1 Son, Grandchildren - Fever . Cough Mycoplasma Pneumonia Family Well-Treatment and Recovery *Fever up to 39’C for 4 hours AUG. 2018 CLUSTER EVENT 3 Unable to Handle Daily Chores Short of Breathiness even resting X Posture, Diurnal Change X Limb Swelling, Chest Tightness, Chest Pain, Palpitation, Wheezing… NYHA Functional Class III - IV OCT. 2018 PROGRESSIVE DYSPNEA 2 VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness
- 8. How the Serial Events Initiated ? 1 Son, Grandchildren - Fever . Cough Mycoplasma Pneumonia Family Well-Treatment and Recovery *Fever up to 39’C for 4 hours AUG. 2018 CLUSTER EVENT 3 OCT. 2018 PROGRESSIVE DYSPNEA 2 Family Members were Disease-Free While Purulent Sputum with Prolonged Cough Persisted SEP. 2018 INTRACTABLE COUGH VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness Unable to Handle Daily Chores Short of Breathiness even resting X Posture, Diurnal Change X Limb Swelling, Chest Tightness, Chest Pain, Palpitation, Wheezing… NYHA III - IV Dyspnea on Exertion
- 9. 掃地 吸地 拖地 擦地 煮飯澆花 洗碗 倒垃圾 爬樓梯 洗衣 曬衣 燙衣 那時的我，喘到都不能...
- 10. How the Serial Events Initiated ? 1 Son, Grandchildren - Fever . Cough Mycoplasma Pneumonia Family Well-Treatment and Recovery *Fever up to 39’C for 4 hours AUG. 2018 CLUSTER EVENT 3 OCT. 2018 PROGRESSIVE DYSPNEA 2 Family Members were Disease-Free While Purulent Sputum with Prolonged Cough Persisted SEP. 2018 INTRACTABLE COUGH VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness Unable to Handle Daily Chores Short of Breathiness even resting X Posture, Diurnal Change X Limb Swelling, Chest Tightness, Chest Pain, Palpitation, Wheezing… NYHA III - IV Chest HRCT @20181016 Blood Test @201810240.2mg/kg/day 台中慈濟胸腔科 中國附醫 2 MONTHS AFTER S/S
- 11. Ground Glass Infiltration Consolidation Air Bronchogram Subpleural Sparing Suspect Organizing Pneumonitis Traction Bronchiectasis Interlobular Consolidation
- 12. Ground Glass Infiltration Consolidation Air Bronchogram Subpleural Sparing Suspect Organizing Pneumonitis Traction Bronchiectasis Interlobular Consolidation
- 13. Ground Glass Infiltration Consolidation Air Bronchogram Subpleural Sparing Suspect Organizing Pneumonitis Traction Bronchiectasis Interlobular Consolidation
- 14. Ground Glass Infiltration Consolidation Air Bronchogram Subpleural Sparing Suspect Organizing Pneumonitis Traction Bronchiectasis Interlobular Consolidation
- 15. TRACTION BRONCHIECTASIS RETICULAR OPACITIES UPPER / MID LOBE INVOLVED | HRCT CORONAL VIEW VGHTC_IMRH
- 16. How the Serial Events Initiated ? 1 Son, Grandchildren - Fever . Cough Mycoplasma Pneumonia Family Well-Treatment and Recovery *Fever up to 39’C for 4 hours AUG. 2018 CLUSTER EVENT 3 OCT. 2018 PROGRESSIVE DYSPNEA 2 Family Members were Disease-Free While Purulent Sputum with Prolonged Cough Persisted SEP. 2018 INTRACTABLE COUGH VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness Unable to Handle Daily Chores Short of Breathiness even resting X Posture, Diurnal Change X Limb Swelling, Chest Tightness, Chest Pain, Palpitation, Wheezing… NYHA III - IV Chest HRCT @20181016 Blood Test @201810240.2mg/kg/day 台中慈濟胸腔科 中國附醫 2 MONTHS AFTER S/S
- 17. End of Present Illness Hx 6 Hospitalization on 2019/01/20 JAN. 2019 ADMISSION FOR SURVEY 4 Chinese Medicine Worked Sjogren's Syndrome Suspected NOV. 2018 S/S ALLEVIATED !!! 5 Visited VGHTC IMRH OPD for Second Opinion regarding Sjogren's Syndrome DEC. 2018 NO DISCOMFORT VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness Examination @20181024 Cytoplasmic Stain ?
- 18. End of Present Illness Hx 6 Hospitalization on 2019/01/20 JAN. 2019 ADMISSION FOR SURVEY 4 Chinese Medicine Worked Sjogren's Syndrome Suspected NOV. 2018 S/S ALLEVIATED !!! 5 Visited VGHTC IMRH OPD for Second Opinion regarding Sjogren's Syndrome DEC. 2018 NO DISCOMFORT VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness Immunomodulation Agent 地方的中醫診所
- 19. End of Present Illness Hx 6 Hospitalization on 2019/01/20 JAN. 2019 ADMISSION FOR SURVEY 4 Chinese Medicine Worked Sjogren's Syndrome Suspected NOV. 2018 S/S ALLEVIATED !!! 5 Visited VGHTC IMRH OPD for Second Opinion regarding Sjogren's Syndrome DEC. 2018 NO DISCOMFORT VGHTC_IMRH Patient Profile Chief Complaint History of Present Illness中國附醫 台中榮總 Immunomodulation Agent
- 20. 陳 女 士 病歷號隱匿 64 years old 1 2 Patient Profile Past Medical Hx Thyroid Goiter Insomnia w/ intermittent depressive mood s/p partial thyroidectomy in 1999 currently in Euthyroidism Lorazepam 2mg PO TID Duloxetine Hydrochloride 30mg PO QD
- 21. 陳 女 士 病歷號隱匿 64 years old Patient Profile Pedigree Suicide, 57 y/o Fall, 69 y/o Accident, 49 y/o Hyperthyroidism Prostate CA, 63 y/o AMI, 48 y/o No Other Contributory Autoimmune Family History
- 22. 陳 女 士 病歷號隱匿 64 years old 1 2 3 4 5 Patient Profile Relevant Hx Family Hx Not contributory Contact/Cluster Hx Family Members : Son, Grandchild - Mycoplasma Pneumonia Drug Hx URI Symtoms Relief Agent Chinese Medication Travel Hx Not contributory Vaccine/Allergy Hx Not contributory Thyroid Dz - Elder sister w/ Hyperthyroidism Autoimmune - No other known Hx No pets keeping
- 23. Easy, alert, oriented No fever No general malaise No body weight loss Review of System GENERAL 1 | WARD Review of System Physical Examination HEENT Postnasal Dripping No headache No rhinorrhea No dysphagia 2 CV No chest tightness No chest pain No limb swelling No JVE 3
- 24. Mild DOE Mild non-productive cough Silent breath sound No painful breathing No night sweating CHEST GU No hesitancy No burning or pain urination No nocturia No urine amount change GI No heartburn No N/V No pain No bowel habit change 4 5 6 | WARD Review of System Physical Examination Review of System
- 25. Weaker while doing chores No myalgia or back pain No numbness or tingling No swelling or tender joint MUSCULOSKELETAL HEMATOLOGY No bruising tendency No hemorrhagic spots No unhealing wound No frequent getting cold SKIN No rash, papule No palpable mass No hair or nail change 7 8 9 | WARD Review of System Physical Examination Review of System
- 26. | SICCA SYNDROME Review of System Physical Examination Review of System No daily, persistent, troublesome dry eyes for more than 3 months No recurrent sensation of sand or gravel in the eyes No use tear substitutes more than 3 times a dayOCULAR ORAL No daily feeling of dry mouth for more than 3 months No frequently drink liquids to aid in swallowing dry food
- 27. | ACTIVITY OF DAILY LIFE Review of System Physical Examination Review of System BRUSHING UP/DOWN STAIR LAUNDRY TOILET
- 28. BP - 109/71 mmHg PR - 89 /min RR - 18 /min BT - 36.8’C SpO2 : 95% R/A VITAL SIGNS HEENT No lymphadenopahy Pink conjunctiva Anicteric sclera No sinus tenderness No oral ulcer GENERAL Appears her age Good hygiene Cooperative attitude No cardiopulmonary distress Physical Examination | WARD Review of System Physical Examination
- 29. Bilateral coarse BS No hyper-resonance No egophony Symmetric expansion Smooth respiratory pattern CHEST SKIN Mechanic's hand @ bilateral 2-3 fingers No Gottron's sign No Heliotrope Eruption No purpura or rashes ABDOMEN Flat, non-distended Normactive bowel sounds No bruits Soft, no guarding or tenderness No abnormal dullness | WARD Review of System Physical Examination Physical Examination
- 30. | Sign of Dermatomyositis Bilateral 2-3 fingers Radial side Scaling . Pealing Mechanic’s HandM
- 31. L a b o r a t o r y R e s u l t s
- 32. - Increased interstitial infiltration and haziness over both lungs, more on bil. lower lung field - Blunting of right CP angle, R/O pleural effusion or pleural thickening 20190120 2081228 20181228 - Increased interstitial infiltrations over bilateral lower lung fields - Bilateral CP angle blunting, favor pleural effusion or pleural change 20190120
- 33. Interstitial lung disease Suspect Sjogren's syndrome Tentative Diagnosis | ADMISSION VGHTC_IMRH - s/p partial thyroidectomy in 1999 - without medication of eltroxin Thyroid Goiter - Euthyroidism status - SSA + - HRCT
- 34. Progressive Dyspnea on Exertion HRCT - Interstitial Lung Disease Problem Based Practice 喘 | BRIEFING 肺 VGHTC_IMRH
- 35. ｜Heart Failure with Acute Pulmonary Edema ｜Acute Myocardial Infarction ｜Cardiac Tamponade Cardiovascular ｜Sepsis ｜Diabetic Ketoacidosis Metabolic - Endocrine ｜Diffuse parenchymal lung diseases ｜Pneumonia ｜Pneumothorax ｜Pulmonary Embolism ｜Acute Exacerbation of Asthma / COPD Respiratory ｜Anemia ｜Neuropsychiatry Hematology . Others 1 3 2 4 | DIFFERENTIAL DIAGNOSIS OF DYSPNEA VGHTC_IMRH
- 36. ｜Heart Failure with Acute Pulmonary Edema ｜Acute Myocardial Infarction ｜Cardiac Tamponade Cardiovascular ｜Sepsis ｜Diabetic Ketoacidosis Metabolic - Endocrine ｜Diffuse parenchymal lung diseases ｜Pneumonia ｜Pneumothorax ｜Pulmonary Embolism ｜Acute Exacerbation of Asthma / COPD Respiratory ｜Anemia ｜Neuropsychiatry Hematology . Others 1 3 2 4 | DIFFERENTIAL DIAGNOSIS OF DYSPNEA VGHTC_IMRH
- 37. ILD
- 41. Routine Labs Recent & Old CXR Pulmonary Function Tests Ga-67 Scan
- 44. No Identified Potential Cause from Hx Inhaled Inorganic Dust Silicates Carbon Metals Inhaled Organic Dust Thermophillic fungi Animal protein Bacteria Others Gases . Fumes . Vapors
- 50. Pulmonary Function Test 20181106 20190123 FVC 1.24L (55%) Moderately Severe 1.46L (56%) Moderately Severe DLCO 33% Severe Decrease 45% Moderate Decrease
- 51. No evidence of active inflammation is demonstrated in both lung. The mildly increased gallium uptake in the posterior regions of both lungs may be due to mild inflammation. 51 2019 / 01 / 24 Ga-67 Scan VGHTC_IMRH
- 52. Blood Test Latex test for Cryptococcus Antigen - Mycoplasma Pneumonia-IgM 310.0 UNITS/ML Chlamydia pneumonia IgM rapid test - Aspergillus Galactomannan Ag 0.162 Legionella IF Ab < 1:128 Urine Culture Legionella Antigen - Pneumococcal Antigen - Sputum Culture Acid Fast Stain 1+ @0122 - *3 PCR - Quantiferon Assay - Sputum Culture Normal mixed flora presented L a b o r a t o r y R e s u l t s
- 53. Immunologic Panel Autoantibody RF ANA dsDNA RO-52 SSB Ab RO-60 30.5 IU/mL Positive, 1:160 Nucleoplasm - Fine speckled 58.1 WHO units/mL Positive 63 EliA U/ml Negative < 0.3 EliA U/ml Positive 33 EliA U/ml Myositis Specific Ab Mi-2α - NXP2 - PM-Scl75 - PL-12 - Mi-2β +/- SAE1 - Jo-1 - EJ +++ T1F1 - Ku - SRP +/- OJ - MAD5 - PM-Scl100 - PL-7 - RO-52 +++ Thyroid Function Free T4 10.7 pg/mL Anti-TG Ab < 20 IU/ML TSH 4.86 uIU/mL Anti-TPO Ab 190 IU/ML L a b o r a t o r y R e s u l t s
- 54. M M T Right Left Right Left Neck Flexors 3 Quadriceps 4 4 Deltoid 4 4 - Ankle Dorsiflexors 5 5 Biceps 4 + 4 + Gluteus Medius 4 - 4 Wrist Extensors 5 5 Gluteus Maximus 4 + 4 + M a n u a l M u s c l e Te s t i n g - 8
- 55. EMG / NCV Motor conduction study showed normal responses over the right median and ulnar nerves, including the F-wave latencies, median transcarpal and ulnar across-elbow conduction study. Sensory conduction study showed normal responses over the right median, radial and ulnar nerves. Needle EMG showed normal pattern over the right Deltoid muscle. Motor conduction study showed normal responses over the bil. peroneal and tibial nerves, including the F-wave latencies. Sensory conduction study showed normal response over the right sural nerve. H-reflex was symmetric in amplitude and latencies bilaterally. Needle EMG showed normal pattern over the right Iliopsoas muscle. | 20190124 CONCLUSIONS NORMAL EMG/NCV STUDY OVER THE UPPER AND LOWER LIMBS 肌 VGHTC_IMRH
- 56. No significant muscle edema or enhancement of bil. gluteal muscle and thigh muscle can be detected. Focal fat-stranding over the subcutaneous region of the left buttock, superficial to left gluteal maximus muscle, fasciitis can not be ruled out. Right Lower Limb MRI
- 57. EULAR / ACR classification criteria for Adult and Juvenile Idiopathic Inflammatory Myopathies 7.0 Possible Probable Definite Non-IIM 5.3-5.4 5.5-7.4 ≥ 7.5 < 5.3 No Biopsy
- 58. EULAR / ACR classification criteria for Adult and Juvenile Idiopathic Inflammatory Myopathies 7.0 Probable Definite 5.5-7.4 ≥ 7.5 No Biopsy Possible Non-IIM 5.3-5.4 < 5.3
- 59. 眼 乾 口 乾 ？ No daily, persistent, troublesome dry eyes for more than 3 months No recurrent sensation of sand or gravel in the eyes No use tear substitutes more than 3 times a dayOCULAR ORAL No daily feeling of dry mouth for more than 3 months No frequently drink liquids to aid in swallowing dry food
- 60. | 2019/01/22 | SS Impression Grade I-II decrease of function of left parotid & bilateral submandibular glands Sialoscintigraphy S
- 61. 2017 ACR–EULAR Classification Criteria for Primary Sjögren’s Syndrome 4≥ 4 Shirmer test : 2mm/5mins
- 62. | HOSPITAL COURSE 14.2 mg/kg/day 0.9 mg/kg/day Admission Discharge
- 63. tRNA synthetase syndrome with predominant interstitial lung disease Seconday Sjogren's syndrome Final Diagnosis | ADMISSION VGHTC_IMRH - s/p partial thyroidectomy in 1999 - without medication of eltroxin Thyroid Goiter - Euthyroidism status - SSA + - Schimer test + - EJ +++, RO-52 +++ - HRCT
- 64. 實習醫學生｜陳佳菁 指導老師｜陳彥如醫師 指導老師｜謝佳偉醫師 | 2019 . 01 . 31 VGHTC_IMRH 謝謝您
- 65. Interstitial Pneumonia with Autoimmune Features | CLASSIFICATION CRITERIA
- 66. Morphologic | HRCT - NSIP W/ OP OVERLAP | UNEXPLAINED PFT VGHTC_IMRH
- 67. Clinical | DISTAL DIGITAL FISSURING VGHTC_IMRH
- 68. Serologic | RF ≥ 2X ULN | ANTI-RO | ANTI-TRNA SYNTHETASE (EJ) VGHTC_IMRH
- 69. Laboratory Results No Elevation of Myositis / Inflammatory Markers
- 70. Immunologic Panel Autoantibody RF ANA dsDNA RO-52 SSB Ab RO-60 30.5 IU/mL Positive, 1:160 Nucleoplasm - Fine speckled 58.1 WHO units/mL Positive 63 EliA U/ml Negative < 0.3 EliA U/ml Positive 33 EliA U/ml Complement C3 C4 116.5 mg/dl 23.2 mg/dL Immunoglobin IgG Total IgE 1611 mg/dl 80.4 kU/l Inflammation Index Ferritin ESR 54.5 ng/ml 31 MM/HR Others Cellfree IL-2R 245.4 pg/ml Laboratory Results / 20181228