Case report 2015/05/13 Reporter：王萱民.

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1 Case report 2015/05/13 Reporter：王萱民

2 Background 林xx Female 68 year-old 157 cm 52.4 Kg BMI 21.2 Diagnosis
Leiomyosarcoma Cholescystitis Breast cancer Uterine myoma

3 Brief History 1994 Uterine myoma Total abdominal hysterectomy
Cholecystitis Laparoscopic cholecystectomy Right breast cancer Radical mastectomy Left breast cancer Radical mastectomy 2015/ Finding fist-sized hard nodule at suprapubic area 2015/04/ Admission Diagnosis : Pelvic tumor Treatment : Debulking surgery and biopsy of the tumor

4 2015/04/ Debulking surgery Retroperitoneal tumor excision + sigmoid colon resection with side-to-end anastomosis of rectum and descending colon Bilateral ureteral catheter insertion 2015/04/ Port-A implantation 2015/04/ Chemotherapy st Gemzar 2015/04/ Discharge 2015/05/ Admission Diagnosis : Leiomyosarcoma G1 Treatment : Chemotherapy with 1st Gemzar and Taxotere

5 Introduction Leiomyosarcoma

6 Leiomyosarcoma (LMS) An aggressive soft tissue sarcoma derived from smooth muscle cells typically of uterine, gastrointestinal or soft tissue origin Uterine sarcomas are a rare and aggressive form of uterine cancer, and usually have a poorer prognosis Leiomyosarcoma of the Uterus (ULMS) : A Review An ESUN Article By Sue Ghosh, MD; Jonathan Hecht, MD, PhD; Tanaz Ferzandi, MD and Christopher Awtrey, MD

7 Staging from The International Federation of Gynecology and Obstetrics (FIGO)
LMS should be grouped with regard to the degree of differentiation as follows:  G1 : 5 percent or less of a nonsquamous or nonmorular solid growth  G2 : 6 percent to 50 percent of a nonsquamous or nonmorular solid growth  G3 : More than 50% of a nonsquamous or nonmorular solid growth Treatment Surgical intervention Radiotherapy Chemotherapy Dietary guideline High-calorie , high-protein

8 Diet history 104/4/10 ~ 104/4/16 NPO with TPN (Clinimix 1506 mL)
104/4/ Water with TPN (Clinimix 1506 mL) 104/4/ Clear liquid diet 104/4/19 ~ 104/4/ Hospital diet : Soft diet 104/4/24 ~ 104/4/ Hospital diet : Low residue diet 104/4/29 ~ Self prepared : Low residue diet

9 SOAP

10 Subjective 病人主訴手術有動到腸子，有護理師表示需吃低渣飲食，但不知 道低渣飲食要如何選擇食物
目前訂購醫院軟質飲食，餐點可全部吃完

11 Objective Lab data 4/23 Height = 157.0 cm Weight = 52.4 Kg BMI = 21.3
4/7 4/9 RBC 4.48 Hb 12.7 12.4 PLT 302 WBC 8.21 UN 20.3 CRE 0.7 Na 143 140.5 K 4.2 Lab data 4/23 Height = cm Weight = 52.4 Kg BMI = 21.3 Ideal body weight= 54.2 kg Diet order : 軟質飲食 Estimated energy requirement : 1650 kcal/day Estimated protein requirement : 81 g/day Estimated energy intake : 1850 kcal/day Estimated protein intake : 77 g/day

12 藥物使用 商品名 用量 頻率 藥物作用 Indol Gel 1% 1 XX PRN 消炎、止痛 MGO Tablet 250 mg/tab
TID 軟便劑；制酸劑

13 Assessment Body weight : in normal range
Estimated energy intake : adequate Estimated protein intake : fair Nutrition knowledge : poor

14 Plan 婦科癌症病患手術後若是預後較差，容易有腸阻塞的現象發生 建議使用低渣飲食

15 Plan 衛教對象：病人本人 低渣飲食衛教 避免攝取牛奶及奶類製品 肉類：攝取去皮去筋的嫩肉，避免油炸、油煎者
蛋類：避免攝取煎蛋、荷包蛋，蒸蛋可 豆類：加工精製品如豆漿、豆腐、豆干可 油炸豆製品或未加工整顆豆 類避免 蔬菜類：避免粗纖維多的蔬菜如竹筍及芹菜、菜梗、老葉 水果類：各種過濾果汁及纖維少的去皮去籽水果 如木瓜、哈密瓜、蓮霧、西瓜可攝取 避免未過濾果汁及含高纖維水果如棗子、番石榴 油脂類：避免攝取堅果類

16 SOAP

17 Subjective Hospital diet 低渣飲食：可吃到約2/3的量，但是隨餐附的果汁沒有喝
除醫院飲食外會吃一點點蛋白質類食物，如魚肉、干貝、蝦子 病人表示最近想要快點增重 明天開始化療，共六次分五個月進行 病人詢問隨餐送的果汁能不能喝與是否需要額外買安素補充營養

18 Objective Lab data 4/27 Height = 155.5 cm Weight = 48.7 Kg BMI = 20.14
4/7 4/9 RBC 4.48 Hb 12.7 12.4 PLT 302 WBC 8.21 UN 20.3 CRE 0.7 Na 143 140.5 K 4.2 Lab data 4/27 Height = cm Weight = 48.7 Kg BMI = 20.14 Ideal body weight= 53.2 kg Diet order : 低渣飲食 Estimated energy requirement : 1650 kcal/day Estimated protein requirement : 80 g/day Estimated energy intake : 1300 kcal/day Estimated protein intake : 60 g/day

19 藥物使用 商品名 用量 頻率 藥物作用 Indol Gel 1% 1 XX PRN 消炎、止痛 Saline Injection 0.9%
500 mL (1 bag) ONCE 水分及電解質之補充 Cefa for Injection 1000 mg (1 vial) 抗生素－頭孢子菌類 MGO Tablet 250 mg/tab 1 tab TID 軟便劑；制酸劑 Paramol Tablet QID 解熱、止痛

20 Assessment Body weight : in normal range
Estimated energy intake : inadequate Estimated protein intake : inadequate Nutrition knowledge : fair

21 Plan 說明需要使用口服營養品的狀況 高蛋白飲食衛教 含蛋白質食物介紹：豆魚肉蛋奶類 含蛋白質食物代換概念教導
建議每日攝取8份含蛋白質類食物 低微生物飲食原則衛教 避免生食 避免攝取鮮奶及優酪乳和養樂多等發酵乳製品，奶粉泡的牛奶可以喝 水果選擇可去皮者

22 SOAP

23 Subjective 目前訂購外賣營養餐，並表示吃太快會腹痛及脹氣，需要細嚼慢嚥 病人自述目前飲食狀況： 早上起床後喝一杯水，接著吃一根香蕉
早餐：營養餐 ─ 瘦肉粥8分滿 午餐：營養餐 ─ 白飯8分滿、肉類和青菜都有吃完 晚餐：營養餐 ─ 白飯8分滿、肉類和青菜都有吃完 餐間會吃水果，除早上的香蕉外一天可再吃掉一個小的木瓜 上星期剛出院時在家吃牛肉+魚肉粥 或 鱸魚湯 或 香菇雞湯 沒有額外攝取點心

24 Objective Lab data Height = 155.5 cm Weight = 49.9 Kg BMI = 20.6
5/1 RBC 3.79 Hb 10.7 PLT 323 WBC 5.29 Alb 3.5 UN 18.2 CRE 0.6 Na 146 K 4.4 Lab data Height = cm Weight = 49.9 Kg BMI = 20.6 Ideal body weight = 53.2 kg Diet order : 一般飲食自備 (訂購低渣營養餐) Estimated energy requirement : 1850 kcal/day Estimated protein requirement : 80 g/day Estimated energy intake : 1865 kcal/day Estimated protein intake : 80 g/day 海綿蛋糕 341kcal/100g

25 藥物使用 商品名 用量 頻率 藥物作用 Saline Injection 0.9% 500 mL (1 bag) ONCE
水分及電解質之補充 Kytril Injection 3 mg (1 amp) 緩解噁心、嘔吐 Rinderon Injection 8 mg (2 amp) 治療免疫失調的疾病 Diphenhydramine Hydrochloride Injection 3% 30 mg (1 amp) 緩解過敏症狀 Famodine Injection 20 mg (1 amp) 抑制胃酸分泌 Ativan Tablet 2 tab 舒緩焦慮，安眠，肌肉鬆弛 Gemzar 1175 mg (5.88 vial) 抗腫瘤藥物 Taxotere 145 mg (7.25 vial) Gitose 5% KCl 10 mEq + Taita No mL Inj 400 mL(1 btl) / 20 mEq(1 btl) 化療藥物 緩解化療副作用藥物

26 Assessment Body weight : in normal range
Estimated energy intake : adequate Estimated protein intake : adequate Nutrition knowledge : fair

27 Plan 維持目前飲食計畫 低渣飲食 高蛋白高熱量飲食 低微生物飲食 化療副作用飲食原則衛教
食慾不振：少量多餐、高營養濃度或喜愛的食物優先進食 味覺改變：選擇色香味俱全的食物、變換烹調方式 噁心、嘔吐：少量多餐、固液分離、避免太油膩食物 維持體重控制，避免體重下降

28 Meal Plan 份數 CHO (g) PT (g) Fat (g) 早餐 早點 午餐 午點 晚餐 晚點 水果類 2 30 1 蔬菜類 4 20 主食類 13 195 26 低脂肉類 6 42 18 3 中脂肉類 7 5 油脂類 8 40 總計 245 79 63 1863 kcal

29 SOAP on telephone

30 Subjective 現在吃東西較沒胃口，有輕微的噁心嘔吐與味覺改變等副作用症狀出現 因腹部脹氣故進食量減少 病人自述目前飲食狀況：
早上起床後喝一杯水，接著吃一個奇異果 早餐：營養餐 ─ 粥品(含肉末、鱸魚)8分滿 午餐：營養餐 ─ 整份餐點約吃7-8分滿 晚餐：營養餐 ─ 整份餐點約吃7-8分滿 最近因沒有去買故較少吃水果，不敢吃朋友送的切塊水果 沒有額外攝取點心 計畫要使用口服營養品來補充熱量

31 Objective Lab data Height = 155.5 cm Weight = 49.7 Kg (空腹時48 Kg)
BMI = 20.7 Ideal body weight = 53.2 kg Estimated energy requirement : 1850 kcal/day Estimated protein requirement : 80 g/day Estimated energy intake : 1640 kcal/day Estimated protein intake : 71 g/day

32 Assessment Body weight : in normal range
Estimated energy intake : inadequate Estimated protein intake : inadequate Nutrition knowledge : fair

33 Plan 維持目前飲食計畫 低渣飲食 高蛋白高熱量飲食 低微生物飲食 維持體重控制，避免體重下降 可使用藥物輔助幫忙消除腹部脹氣
說明口服營養品的使用及選擇方式 依進食狀況調整營養品使用量，原則上目前每天1-2瓶即可 可以選擇熱量較高的雙卡或倍力素，也可以選擇普通的安素 注意勿選用有添加纖維質營養品

34

35 Conclusion Know and can do low residue diet
Know and can do high-calorie , high-protein diet Preserve weight loss Try to gain weight if possible

36 Thank you for your listening !!