1. 腫瘤科案例 -- Hypercalcemia 案例簡介 Mrs. Lee, a 50-year-old female patient, was diagnosed with left breast cancer T2N1M1,ER(+),PR(+),HER2 (1+) with bone, liver metastases for 3 years. Disease progression with progressive bone pain were noted in recent 2 months. In recent 2 weeks, she had suffered from constipation, weakness, anorexia, fatigue and thirsty. Conscious drowsy were also noted. Hypercalcemia were noted in ER. Hydration and bisphosphanate were supplied. DNR were discussed with her family.

2. 腫瘤科案例 -- Hypercalcemia 學習目標 To identify the hypercalcemia symptoms and signs. To understand the pathophysiology and common causes of hypercalcemia in adults. To identify the significant findings of physical examination in hypercalcemia patients. To identify the significant findings of lab examination in hypercalcemia patients. To understand the indication of bisphosphoate and emergent dialysis. To understand how to confirm the terminal disease. To simulate how to discuss with patient and family DNR.

3. 腫瘤科案例 -- Hypercalcemia 場景 (1): 病史 Mrs. Lee, a 50-year-old female patient, was diagnosed with left breast cancer (invasive ductal carcinoma) T2N1M1,ER(+),PR(+),HER2 (1+) with bone, liver metastases for 3 years. She had received multiple lines palliative chemotherapy. However, progressive bone pain were noted in recent 2 months. Disease progression were confirmed by CT scan and bone scan. She received palliative chemotherapy with taxotere/cisplatin in recent 2 months. In recent 2 weeks, she had suffered from constipation, weakness, anorexia, fatigue and thirsty. Conscious drowsy were also noted. Due to above discomfort, she was admitted via emergency room today.

4. 腫瘤科案例 -- Hypercalcemia 討論 (1): Identify Mrs. Lee’s problems. Generate diagnostic hypotheses that account for one or more of Mrs. Lin’s problems. Prioritize your list of hypotheses. What further information is needed to prove or disprove the hypotheses? What are your preliminary impressions and treatment plans?

5. 腫瘤科案例 -- Hypercalcemia 場景 (2): 身體檢查 Vital sign: BT 36.8 ℃, PR 110/min, RR 22/min, BP 100/50 mmHg, BW 55 kg; Conscious: drowsy, E3V4M5; skin: dry Eye: pale conjunctiva, no icteric sclera Neck: supple, no JVE, no palpable lymph node Chest: Breath sound clear, s/p left MRM Heart: regular heart beat without murmur, tachycardia, Abdomen: soft and mild distented, no abdominal tenderness, no rebounding pain, hypoactive bowel sound, Back: no costovetebral angle knocking pain Extremities: leg no pitting edema

6. 腫瘤科案例 -- Hypercalcemia 場景 (2): 檢驗檢查 BUN 20 Cr 1.1 (T)bil 0.8 AST 66 ALT 37 ALK-p 341 Ca >15 Albumin 3.0 WBC 15000 Hb 10 Platelet 250000 Seg 50%

7. 腫瘤科案例 -- Hypercalcemia 案例討論 (2): What are the major findings of the laboratory examination of Mrs. Lee? What further examinations do you need to confirm your diagnostic hypotheses? What do you want to do for the patient now?

8. 腫瘤科案例 -- Hypercalcemia 場景 (3): 確認診斷與後續治療計畫 After hydration and bisphosphonate treatment, Mrs. Lee’s conscious status was mild improving. We close monitor her fluid status. However, the serum examination follow-up still showed Ca 13.3. She was still weakness. Repeated CT scan showed new lung lesions. Patient’s son asked about the further treatment plan.

9. 腫瘤科案例 -- Hypercalcemia 討論 (3): What are your main diagnoses of this patient? And, what is the process of causal reasoning? What are your further treatment plans?

10. 腫瘤科案例 -- Hypercalcemia 場景 (4): 醫病溝通 Due to her disease persist progressed in spite of multiple lines palliative chemotherapy, besides, her performance status is also poor. Further chemotherapy may be not suitable. So how to discuss with patient and her family about DNR.

11. 腫瘤科案例 -- Hypercalcemia 案例討論 (4): How to discuss with DNR