s*******2
发帖数: 1182 | 1 任何关于胸片，CT,核磁共振等方面的咨询，请在此跟帖，Dr.jeff811会抽空回答您的
问题。 |
s*******2
发帖数: 1182 | 2 发信人: myjob (myjob), 信区: Medicine
标 题: 大牛们帮忙，在医院里当作疑难杂症.
发信站: BBS 未名空间站 (Fri Jul 25 22:50:38 2014, 美东)
一个半月以前朋友他父亲 74岁 外出四川旅游归来，出现发热腹泻并出现语言功能障碍
表现为逻辑思维混乱表达欠切题。无恶心，呕吐，无四肢抽搐及呼吸困难，无两便失禁
，门诊以左额叶占位收入神经外科。MRI 显示左侧额叶病灶, 脓肿可能性比较大。感染
指标未检出抗酸杆菌隐球菌，真菌， G双球菌。感染科会诊后颅內病变考虑结核瘤可能
。6月26号患者出现右侧肢体偏瘫，肌力3级，7月8号出发寒颤高热气温高达四十度。当
日肺部感染严重，行气管切开后氧饱和废在百分之七十到百分之八十之间，转入神经内
科爱ICU病房。患者每日出现寒战高热发作及持续时间不定，最高气温十四度。免疫学
抗核抗体，抗中性粒细胞浆，活化淋巴细胞无异常。血培养涂片，痰培养涂片，尿培养
无明确病原学证据。各项感染指标均增高。大牛们帮忙，在医院里当作疑难杂症.
感谢大牛们给点建议 |
s*******2
发帖数: 1182 | 3 发信人: steve2012 (steve), 信区: Medicine
标 题: Re: 大牛们帮忙，在医院里当作疑难杂症.
发信站: BBS 未名空间站 (Mon Jul 28 23:56:58 2014, 美东)
经LZ 同意，将患者CT 贴在此处：
http://medpic.weebly.com |
s*******2
发帖数: 1182 | 4 DR JEFF ,有时间给看一下这个患者的脑CT 和胸部CT. 谢谢。 |
s*******2
发帖数: 1182 | |
j*****1
发帖数: 105 | 6 这两天没时间。
过两天有时间再看看。
【在 s*******2 的大作中提到】
: DR JEFF ,有时间给看一下这个患者的脑CT 和胸部CT. 谢谢。
|
s*******2
发帖数: 1182 | 7 Take your time, thanks.
【在 j*****1 的大作中提到】
: 这两天没时间。
: 过两天有时间再看看。
|
j*****1
发帖数: 105 | 8 I have to say first that I am not neuroradiologist. My training in
neuroradiology is limited to my residency experience.
From the non-contrast enhanced CT head, which is not modality of choice for
brain space occupying lesion, and based on pt's hx, it does look a lot like
a abscess in the left frontal lobe. The lesion is ring-shaped with lots of
edema surrounding it and evidence of mass effect. In pt who developed the
symptoms in such a short period of time, abscess has to be considered first
until proven otherwise. Of course, MRI brain would be the ideal study to
confirm that if you see restricted diffusion in the lesion. Since this is a
non-con study, the ring shape high density could well be ring shaped
bleeding with an underlying lesion such as a tumor or hemorrhagic conversion
from an infarction. However, hx doesn't support that.
As for what is the causative agent, it is very hard to tell from imaging
study, almost impossible unless you have other imaging studies to support a
particular agent such as a typical CXR of TB or serum study of a particular
fungal infection. For some reason I couldn't open the CXR. If the pt has an
cavitary lesion in the lung with hx of traveling to an endemic area, I think
TB should be high in the top of differential.
MRI should have been done. Empiric abx therapy should have started.
Neurosurgeon shall have been consulted for a possible surgery to decompress
the pressure. Pt won't last long if it gets worse.
OK, Now I see the MRI and CT chest. Looks like the MRI is typical for
abscess. However no DWI image there for some reason. The CT chest looks like
having some cavitary lesions in the left apical lung.
Based on all the imaging and hx. TB has to be consider top of differential
until proven otherwise. At least some sort of atypical macrobacterial
infection/fungal infection should be first consideration.Bacterial infection
certainly possible. Abx treatment should be on and neurosurgeon consulted.
Did they do bx? sounds crazy but some time they do. I am not quite clear
about the labs.
Just my 2 cents.
Thanks
【在 s*******2 的大作中提到】
: Take your time, thanks.
|
s*******2
发帖数: 1182 | 9 thank you very very much, very sharp and detailed report. hope patient's
family can bring this second opinion to his primary doctors. |
A*S
发帖数: 354 | 10 Dr. Jeff, 这是一个患者吃了米线后的胃CT, 这个正常吗？ |
|
|
t*****t
发帖数: 24 | 11 医生您好，
我父亲74岁，便黑便，做胃镜。有出血后结痂。有2.5cm异物。请看截图。
问题：
所有胃镜的图片，深色的是用NBI的镜子开的，不是很明确。想问一下PET-CT在明确这
个部位肿瘤的准确性有多高？行PET-CT检查如出现阳性结果可以和胃溃疡鉴别吗
谢谢！ |
j*****1
发帖数: 105 | 12 I am not GI doctor. Let me just tell you what I think. I think they are
trying to figure out whether it is bleeding caused by benign gastric ulcer
or bleeding gastric tumor. Endoscopy still is the best way to go. What's
more, you need biopsy to make the final diagnosis no matter what. Endoscopy
is only way to get it unless you will have a surgery. PET/CT really is not
that sensitive nor specific for small GI tumor. If it is very positive, of
course it will suggests the possibility. If it is kind of positive, you
really can't be sure.
【在 t*****t 的大作中提到】
: 医生您好，
: 我父亲74岁，便黑便，做胃镜。有出血后结痂。有2.5cm异物。请看截图。
: 问题：
: 所有胃镜的图片，深色的是用NBI的镜子开的，不是很明确。想问一下PET-CT在明确这
: 个部位肿瘤的准确性有多高？行PET-CT检查如出现阳性结果可以和胃溃疡鉴别吗
: 谢谢！
|
t*****t
发帖数: 24 | 13 再问问，因为病变位于胃后壁，质地偏硬，胃镜下活检钳夹取的组织很碎很小，病理中
仅看到少许异形细胞。请问还有什么方法可以取到更大些的组织吗
Endoscopy
【在 j*****1 的大作中提到】
: I am not GI doctor. Let me just tell you what I think. I think they are
: trying to figure out whether it is bleeding caused by benign gastric ulcer
: or bleeding gastric tumor. Endoscopy still is the best way to go. What's
: more, you need biopsy to make the final diagnosis no matter what. Endoscopy
: is only way to get it unless you will have a surgery. PET/CT really is not
: that sensitive nor specific for small GI tumor. If it is very positive, of
: course it will suggests the possibility. If it is kind of positive, you
: really can't be sure.
|
j*****1
发帖数: 105 | 14 I am not really sure. I think it has to be discussed with GI doc or surgeon.
Repeat endo or surgery might be the only way to get more tissue.
【在 t*****t 的大作中提到】
: 再问问，因为病变位于胃后壁，质地偏硬，胃镜下活检钳夹取的组织很碎很小，病理中
: 仅看到少许异形细胞。请问还有什么方法可以取到更大些的组织吗
:
: Endoscopy
|
A****3
发帖数: 87 | 15 如果是卵巢癌第二期（2B) 做幾次化療才能沒有癌細胞，是否沒有癌細胞就停止還是要
繼續整個療程6次? 化療如何減少副作用? 謝謝! |
s*******2
发帖数: 1182 | 16 任何关于胸片，CT,核磁共振等方面的咨询，请在此跟帖，Dr.jeff811会抽空回答您的
问题。 |
s*******2
发帖数: 1182 | 17 病例一：
一个半月以前朋友他父亲 74岁 外出四川旅游归来，出现发热腹泻并出现语言功能障碍
表现为逻辑思维混乱表达欠切题。无恶心，呕吐，无四肢抽搐及呼吸困难，无两便失禁
，门诊以左额叶占位收入神经外科。MRI 显示左侧额叶病灶, 脓肿可能性比较大。感染
指标未检出抗酸杆菌隐球菌，真菌， G双球菌。感染科会诊后颅內病变考虑结核瘤可能
。6月26号患者出现右侧肢体偏瘫，肌力3级，7月8号出发寒颤高热气温高达四十度。当
日肺部感染严重，行气管切开后氧饱和废在百分之七十到百分之八十之间，转入神经内
科爱ICU病房。患者每日出现寒战高热发作及持续时间不定，最高气温十四度。免疫学
抗核抗体，抗中性粒细胞浆，活化淋巴细胞无异常。血培养涂片，痰培养涂片，尿培养
无明确病原学证据。各项感染指标均增高。大牛们帮忙，在医院里当作疑难杂症.
感谢大牛们给点建议。
患者CT 贴在此处：
http://medpic.weebly.com |
s*******2
发帖数: 1182 | 18 DR JEFF ,有时间给看一下这个患者的脑CT 和胸部CT. 谢谢。
http://medpic.weebly.com |
s*******2
发帖数: 1182 | |
j*****1
发帖数: 105 | 20 这两天没时间。
过两天有时间再看看。
【在 s*******2 的大作中提到】
: DR JEFF ,有时间给看一下这个患者的脑CT 和胸部CT. 谢谢。
: http://medpic.weebly.com
|
|
|
s*******2
发帖数: 1182 | 21 Take your time, thanks.
【在 j*****1 的大作中提到】
: 这两天没时间。
: 过两天有时间再看看。
|
j*****1
发帖数: 105 | 22 I have to say first that I am not neuroradiologist. My training in
neuroradiology is limited to my residency experience.
From the non-contrast enhanced CT head, which is not modality of choice for
brain space occupying lesion, and based on pt's hx, it does look a lot like
a abscess in the left frontal lobe. The lesion is ring-shaped with lots of
edema surrounding it and evidence of mass effect. In pt who developed the
symptoms in such a short period of time, abscess has to be considered first
until proven otherwise. Of course, MRI brain would be the ideal study to
confirm that if you see restricted diffusion in the lesion. Since this is a
non-con study, the ring shape high density could well be ring shaped
bleeding with an underlying lesion such as a tumor or hemorrhagic conversion
from an infarction. However, hx doesn't support that.
As for what is the causative agent, it is very hard to tell from imaging
study, almost impossible unless you have other imaging studies to support a
particular agent such as a typical CXR of TB or serum study of a particular
fungal infection. For some reason I couldn't open the CXR. If the pt has an
cavitary lesion in the lung with hx of traveling to an endemic area, I think
TB should be high in the top of differential.
MRI should have been done. Empiric abx therapy should have started.
Neurosurgeon shall have been consulted for a possible surgery to decompress
the pressure. Pt won't last long if it gets worse.
OK, Now I see the MRI and CT chest. Looks like the MRI is typical for
abscess. However no DWI image there for some reason. The CT chest looks like
having some cavitary lesions in the left apical lung.
Based on all the imaging and hx. TB has to be consider top of differential
until proven otherwise. At least some sort of atypical macrobacterial
infection/fungal infection should be first consideration.Bacterial infection
certainly possible. Abx treatment should be on and neurosurgeon consulted.
Did they do bx? sounds crazy but some time they do. I am not quite clear
about the labs.
Just my 2 cents.
Thanks
【在 s*******2 的大作中提到】
: 病例一：
: 一个半月以前朋友他父亲 74岁 外出四川旅游归来，出现发热腹泻并出现语言功能障碍
: 表现为逻辑思维混乱表达欠切题。无恶心，呕吐，无四肢抽搐及呼吸困难，无两便失禁
: ，门诊以左额叶占位收入神经外科。MRI 显示左侧额叶病灶, 脓肿可能性比较大。感染
: 指标未检出抗酸杆菌隐球菌，真菌， G双球菌。感染科会诊后颅內病变考虑结核瘤可能
: 。6月26号患者出现右侧肢体偏瘫，肌力3级，7月8号出发寒颤高热气温高达四十度。当
: 日肺部感染严重，行气管切开后氧饱和废在百分之七十到百分之八十之间，转入神经内
: 科爱ICU病房。患者每日出现寒战高热发作及持续时间不定，最高气温十四度。免疫学
: 抗核抗体，抗中性粒细胞浆，活化淋巴细胞无异常。血培养涂片，痰培养涂片，尿培养
: 无明确病原学证据。各项感染指标均增高。大牛们帮忙，在医院里当作疑难杂症.
|
s*******2
发帖数: 1182 | 23 thank you very very much, very sharp and detailed report. hope patient's
family can bring this second opinion to his primary doctors. |
A*S
发帖数: 354 | 24 Dr. Jeff, 这是一个患者吃了米线后的胃CT, 这个正常吗？ |
t*****t
发帖数: 24 | 25 医生您好，
我父亲74岁，便黑便，做胃镜。有出血后结痂。有2.5cm异物。请看截图。
问题：
所有胃镜的图片，深色的是用NBI的镜子开的，不是很明确。想问一下PET-CT在明确这
个部位肿瘤的准确性有多高？行PET-CT检查如出现阳性结果可以和胃溃疡鉴别吗
谢谢！ |
j*****1
发帖数: 105 | 26 I am not GI doctor. Let me just tell you what I think. I think they are
trying to figure out whether it is bleeding caused by benign gastric ulcer
or bleeding gastric tumor. Endoscopy still is the best way to go. What's
more, you need biopsy to make the final diagnosis no matter what. Endoscopy
is only way to get it unless you will have a surgery. PET/CT really is not
that sensitive nor specific for small GI tumor. If it is very positive, of
course it will suggests the possibility. If it is kind of positive, you
really can't be sure.
【在 t*****t 的大作中提到】
: 医生您好，
: 我父亲74岁，便黑便，做胃镜。有出血后结痂。有2.5cm异物。请看截图。
: 问题：
: 所有胃镜的图片，深色的是用NBI的镜子开的，不是很明确。想问一下PET-CT在明确这
: 个部位肿瘤的准确性有多高？行PET-CT检查如出现阳性结果可以和胃溃疡鉴别吗
: 谢谢！
|
t*****t
发帖数: 24 | 27 再问问，因为病变位于胃后壁，质地偏硬，胃镜下活检钳夹取的组织很碎很小，病理中
仅看到少许异形细胞。请问还有什么方法可以取到更大些的组织吗
Endoscopy
【在 j*****1 的大作中提到】
: I am not GI doctor. Let me just tell you what I think. I think they are
: trying to figure out whether it is bleeding caused by benign gastric ulcer
: or bleeding gastric tumor. Endoscopy still is the best way to go. What's
: more, you need biopsy to make the final diagnosis no matter what. Endoscopy
: is only way to get it unless you will have a surgery. PET/CT really is not
: that sensitive nor specific for small GI tumor. If it is very positive, of
: course it will suggests the possibility. If it is kind of positive, you
: really can't be sure.
|
j*****1
发帖数: 105 | 28 I am not really sure. I think it has to be discussed with GI doc or surgeon.
Repeat endo or surgery might be the only way to get more tissue.
【在 t*****t 的大作中提到】
: 再问问，因为病变位于胃后壁，质地偏硬，胃镜下活检钳夹取的组织很碎很小，病理中
: 仅看到少许异形细胞。请问还有什么方法可以取到更大些的组织吗
:
: Endoscopy
|
A****3
发帖数: 87 | 29 如果是卵巢癌第二期（2B) 做幾次化療才能沒有癌細胞，是否沒有癌細胞就停止還是要
繼續整個療程6次? 化療如何減少副作用? 謝謝! |
s*******c
发帖数: 42 | 30 同学家人患癌了，压力很大。
哪位专家能帮忙看看片子？
链接如下
http://en.mail.qq.com/cgi-bin/ftnExs_download?k=08613531a124169
【在 s*******2 的大作中提到】
: 任何关于胸片，CT,核磁共振等方面的咨询，请在此跟帖，Dr.jeff811会抽空回答您的
: 问题。
|
|
|
c**********8
发帖数: 8 | 31 请帮看看下面胸片结果，需要作CT 或支气管镜、活检吗？请给出您的建议，非常感谢！
祝圣诞、新年快乐！
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
PA lateral chest
There are no prior exams available
There is a 21 x 11 mm density within the right infrahilar region
Remainder of the lungs are clear
There is no pneumothorax or effusion
Cardiac silhouette is not enlarged
Impression:
Possible 21 x 11 mm nodular infiltrate right infrahilar region. |
c*********9
发帖数: 263 | 32 Dr. Jeff
亲戚最近一段时间一直有头晕、胸痛，去上海中山医院作了超声波和CT检查（见附件）
。诊断结果好像是肺动脉高压和冠动脉钙化、堵塞。请问这个问题严重么？这里有没有
有经验的医师？国内的医生解释的不是很清楚。谢谢！ |
c*********9
发帖数: 263 | 33 附件
没有
【在 c*********9 的大作中提到】
: Dr. Jeff
: 亲戚最近一段时间一直有头晕、胸痛，去上海中山医院作了超声波和CT检查（见附件）
: 。诊断结果好像是肺动脉高压和冠动脉钙化、堵塞。请问这个问题严重么？这里有没有
: 有经验的医师？国内的医生解释的不是很清楚。谢谢！
|
j*****1
发帖数: 105 | 34 我不是心脏科的。但从报告看没啥大问题。轻度肺动脉高压应该不是大问题。但要心脏
科医生联系临床症状来判断。冠狀动脉钙化老年人很普遍。报告说轻微狭窄。那就没大
问题。如果需要可以进一步做stress test to check signs of cardiac ischemia.
Please check with cardiologist also.
【在 c*********9 的大作中提到】
: 附件
:
: 没有
|
j*****1
发帖数: 105 | 35 应该问肿瘤科。不过没有人能知道几次化疗能杀死所有癌细胞。影像学和肿瘤标志物检
查都是辅助检查。要终生follow up.
【在 A****3 的大作中提到】
: 如果是卵巢癌第二期（2B) 做幾次化療才能沒有癌細胞，是否沒有癌細胞就停止還是要
: 繼續整個療程6次? 化療如何減少副作用? 謝謝!
|
j*****1
发帖数: 105 | 36 You need a CT chest with contrast and/or PET/CT for further evaluation.
Based on what you see in those studies. May need a bronchoscopy to biopsy to
make final diagnosis. Needs to talk to pulmonogist or oncologist.
谢！
【在 c**********8 的大作中提到】
: 请帮看看下面胸片结果，需要作CT 或支气管镜、活检吗？请给出您的建议，非常感谢！
: 祝圣诞、新年快乐！
: －－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
: PA lateral chest
: There are no prior exams available
: There is a 21 x 11 mm density within the right infrahilar region
: Remainder of the lungs are clear
: There is no pneumothorax or effusion
: Cardiac silhouette is not enlarged
: Impression:
|
