Case report 2015/05/13 Reporter：王萱民

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

Brief History 1994 Uterine myoma Total abdominal hysterectomy Cholecystitis Laparoscopic cholecystectomy 2005 Right breast cancer Radical mastectomy 2012 Left breast cancer Radical mastectomy 2015/03 Finding fist-sized hard nodule at suprapubic area 2015/04/07 Admission Diagnosis : Pelvic tumor Treatment : Debulking surgery and biopsy of the tumor

2015/04/09 Debulking surgery Retroperitoneal tumor excision + sigmoid colon resection with side-to-end anastomosis of rectum and descending colon Bilateral ureteral catheter insertion 2015/04/27 Port-A implantation 2015/04/28 Chemotherapy 1st Gemzar 2015/04/29 Discharge 2015/05/04 Admission Diagnosis : Leiomyosarcoma G1 Treatment : Chemotherapy with 1st Gemzar and Taxotere

Introduction Leiomyosarcoma

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

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

Diet history 104/4/10 ~ 104/4/16 NPO with TPN (Clinimix 1506 mL) 104/4/17 Water with TPN (Clinimix 1506 mL) 104/4/18 Clear liquid diet 104/4/19 ~ 104/4/23 Hospital diet : Soft diet 104/4/24 ~ 104/4/28 Hospital diet : Low residue diet 104/4/29 ~ Self prepared : Low residue diet

SOAP 1 2015.04.23

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

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 = 157.0 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

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

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

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

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

SOAP 2 2015.04.27

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

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 = 155.5 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

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

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

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

SOAP 3 2015.05.04

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

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 = 155.5 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

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.5 400 mL Inj 400 mL(1 btl) / 20 mEq(1 btl) 化療藥物 緩解化療副作用藥物

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

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

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

SOAP 4 2015.05.08 on telephone

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

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

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

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

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

Thank you for your listening !!