口腔病理學 病歷報告暨醫學倫理討論

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口腔病理學

病歷報告暨醫學倫理討論

組別: Intern K

組員: 羅允隆 雲婉芬 李國煒 紀秉皓

指導醫師: 陳玉昆醫師暨口病科全體醫師 報告日期: 102.6.25

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General Data

Name: ○ ○ ○ Gender: Female Age: 36 y/o

Native: 台灣高雄 Marital status: 已婚

Attending V.S.: ○ ○ ○醫師 First visit: 2013/ ○ / ○ /

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Chief Complaint

Referred from小港hospital 牙科for further evaluation of an exophytic mass over the left palate

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Present Illness

This 36 y/o female found there was an exophytic mass over the Lt palate for about 3 years, and one month ago,she went to 小港hospital 牙科for examination, receiving incisional biopsy & MRI.

The histopathological report was pleomorphic adenoma, so she was referred to our OS OPD for further operation treatment.

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Intraoral Examination examination

Location: Left hard palate corresponding to the palatal side of tooth 25, 26 and near the midline

Max. dimension: 2×2cm Color: Pinkish

Consistency: Rubbery Pain: (-)

Tenderness: (-)

Surface: smooth, non-ulcerated Dome shaped

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Coronal view

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Axial view

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Sagital view

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MRI

05/09/2013

A hyperintense nodule on T2WI, 1.5x1.2x1.1cm, in

the junction of the hard palate and soft palate.

(Se/Im: 5/12 and 7/15) Suggest clinical correlation and follow up.

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Personal Habits

Risk factors related to malignancy Alcohol:(-)

Betel quid: (-) Cigarette: (-)

Special oral habits : Denied Bite irritation : Denied

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Past Medical History

Underlying disease: (-) Hospitalization: (+), CS

Surgery under GA: (+), CS

Food or drug allergies : Denied

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Past Dental History

General routine dental treatment

Attitude to dental treatment: co-operative

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Panorex

05/28/2013

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Dental finding

Missing: Tooth 36, 38, 46, 48 Impaction: Tooth 28

Rotation: Tooth 23

Mesial tilting: Tooth 37,47 Caries: Tooth 33

Generalized horizontal bony defect

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Differential Diagnosis

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Classification of the lesion

1)Intrabony or Peripheral?

2)Inflammation, Neoplasm or Cyst?

3)Benign or Malignant?

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Peripheral or intrabony?

Our case peripheral Intrabony Mucosal

lesion

+ + -

Bony

expansion

- - + / -

Cortical bone destruction

- - + / -

Peripheral

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Inflammation ? Neoplasm ? Cyst ?

Our case Inflamma

tion Neoplasm Cyst

Color Pinkish Red Variable

Yellow or white

Fever or

local heat (-) (+) (-) (-)

Consistenc

y Firm Rubbery Variable Rubber

y

Ulceration (-) (-) (-)/(+) (-)

Duration 2-3 years Days to Months

Months to

years Years

Mobility Fixed (in palate)

Fixed (in palate)

Fixed (in palate)

Fixed (in palate)

Pain (-) (+) (-)/(+) (-)

Neoplasm

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Benign or Malignancy ?

Our case Benign Malignancy

Surface Smooth Smooth Rough

progressive Slow-

progressing Slow Variable

Pain - +/- +/-

mobility

(in palate) Fixed Fixed Fixed

Benign

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Working Diagnosis

1) Pleomorphic adenoma 2) Myoepithelioma

3) Fibroma

4) Warthin’s tumor

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1) Pleomorphic Adenoma

Our case Pleomorphic adenoma

Gender Female Female

Age 36 30~60

Site Palate 最常見於parotid gland ,若發生

在minor gland 則好發於palate。

pain - -

swelling + +

drainage - -

Shape Smooth, dome shape Firm single nodular

Duration 2-3 years Slow

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2) Myoepithelioma

Our case myoepithelioma

Gender Female Female

Age 36 years

Mostly occurs in the 5th and 6th decade of

life.

Site Palate Parotids(40 %)

Palatal minor glands (21%)

pain - -

swelling + +

Drainage - -

Shape Smooth, dome shape

Duration 2-3 years Slow growing

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3) Fibroma

Our case Fibroma

Gender Female Equal

Age 36 40~60

Site Palate Buccal mucosa

pain - -

swelling + +

Drainage - -

Shape Smooth, dome shape Pedunculated, round shape

Duration 2-3 years Slow

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4) Adenolymphoma (Warthin’s tumor

Our case Warthin tumor

Gender Female Male

Age 36 60~70

Site Palate The tail of the parotid gland

near the angle of the mandible

pain - -

swelling + +

drainage - -

Shape Smooth, dome shape Firm or fluctuant, bilateral but may not metachronous

Duration 2-3 years slow

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Clinical impression

Pleomorphic adenoma over the left palate.

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Treatment

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Treatment procedure

102.04.27

Referred from 小港醫院 牙科

102.05.18

1. Collect GA routine data, panorex 2. Impression of stent fabrication

3. Operation has arranged on 102.05.30

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Treatment Plan

術式( 102.05.30 ):

Excision + stent fixation + terudermis repair

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Operation under GA

About 1 mm nasal floor perforation was noted during operation (102.05.30)

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Operation under GA

used terudermis 2.5 x 2.5 cm to cover the surgical defect with surgical stent fixation (102.05.30)

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Operation under GA

specimen photo record (102.05.30)

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OPD follow up

102.06.08

1. Wound condition : stable 2. Fixation in place

102.06.15

1. Remove palatal stent & circumdental wiring 2. Tiny perforation(1x1 mm)

提醒病人不要用吸管,打噴嚏嘴巴要打開

4. N.V. 回小港醫院追蹤

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Discussion

Pleomorphic Adenoma

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Introduction

●Pleomophic adenoma is a mixed benign tumor which is the most common of all

salivary gland neoplasms.

●Its most common location is the parotid gland (85%).

●This tumor is mostly diagnosed in the 4th-

6th decades of life.

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Clinical Features

• Sex predilection: Female>Male

• Slowly growing

Painless

Firm mass

• Smooth lobulated appearance

• It tends to be mobile when small but may become fixed with advanced

growth.

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Etiology & Pathogenesis

腫瘤細胞雖有多種型態,也有類似間質細胞樣的間

質(mesenchyme-appearing “stroma”),來源 為管腔上皮細胞與myoepithelial cell

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Treatment

• Surgical excision is the frequent choice

• Recurrence rate is < 2%

• Facial nerve palsy & the auriculotemporal syndrome may be the common

complications (lesion in parotid gland)

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醫學倫理討論

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醫學倫理與全人照護

醫學倫理:一種道德思考、判斷和決策,以倫理

學的觀點出發,以期能做出對病人最有利益、最 能符合道德倫理規範的醫療決策

醫病關係的轉變:醫師中心模式轉變為病人中心

模式 (physician-centered model → patient- centered model)

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醫學倫理四大原則

• 自主原則(Autonomy)

• 不傷害原則(Non-maleficence)

• 行善原則(Beneficence)

• 公義原則(Justice)

Tom Beauchamp & James Childress在1979提出

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1.自主原則(Autonomy)

原則:

一位具理性思考能力的病人,在完全瞭解醫療處置 方針的利弊得失下,有權決定自己的行為,包括 決定及選擇醫療專業人員和治療方式

臨床意義

(1) 病人之自主行為不應遭受他人之操控或干預 (2)指醫療人員應提供充分且適當之資訊,以促成 病人針對診療方式主動作一抉擇

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2.不傷害原則(Non-maleficence)

原則:

不殺害病人、不能侵害病人權益和福祉以及平衡利 害得失,使痛苦減到最低

臨床意義

(1)醫療上是必須的,或是屬於醫療適應症範圍,

因所施行的各種檢查或治療而帶來的傷害應符 合不傷害原則

(2)權衡利害原則 → 兩害相權取其輕 (3)保護病人的生命安全

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3.行善原則(Beneficence)

原則:

行善原則包括不傷害原則的反面義務(不應該做的事)和 確有助益的正面義務(應該做的事),包括維護和促進 病人的健康、利益和福祉,為基本倫理原則,也是醫 護人員的基本義務

臨床意義

(1) 勿施傷害:不得故意對他人施予傷害或惡行 (2) 預防傷害:應該預防傷害或惡行

(3) 移除傷害:應該移除傷害或惡行

(4) 維持善行:應該致力於行事或維持善行

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4.公義原則(Justice)

原則:

強調資源合理分配、賞罰分明以及合乎正義之事。

醫療上公平原則指基於正義與公道,以公平合理 的態度來對待病人、病人家屬和受影響的社會大

臨床意義

(1) 公平地分配不足的資源 (2) 尊重病人的基本權利

(3) 尊重道德允許的法律及法律之前人人平等 (4) 先來先服務與急重症優先

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全人照護的定義

Total patient care :

a method of organizing care of patients such that one practitioner carries out all care

requirements

國內有人闡述為:

以推動全人照護醫療為出發點,以病患為治療中 心,經詳細診查,訂定符合病患需求的治療計劃,

並由一位醫師統合病患的整體治療及執行大部份 的牙科治療項目,能使病患能獲得更好的治療效 果

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臨床案例討論

本案例符合自主原則 (Autonomy)

病人已了解自己的病狀 ,治療方法(f/u ,手術) 復發的可能性,併發症

本案例符合行善原則

(Beneficence) 預防傷害,移除傷害

本案例符合不傷害原則(Non- maleficence)

因所施行的各種檢查或治療而帶來的傷害應 符合不傷害原則

最後,整個治療過程不只是關心到病人的身體上的病狀,

也包含病人生活上的品質與心理上的照顧,符合全人照 顧的考量

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Reference

http://oralpathol.dlearn.kmu.edu.tw/

žOral and maxillofacial pathology, 3rd edition, Neville

Essentials of Oral Pathology, 3rd Edition

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Thanks for your attention!!

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