口腔病理學 病歷報告暨醫學倫理討論

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

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/ ○ / ○ /

Chief Complaint

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

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.

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

Coronal view

Axial view

Sagital view

MRI

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.

Personal Habits

Risk factors related to malignancy Alcohol：(-)

Betel quid: (-) Cigarette: (-)

Special oral habits : Denied Bite irritation : Denied

Past Medical History

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

Surgery under GA: (+), CS

Food or drug allergies : Denied

Past Dental History

General routine dental treatment

Attitude to dental treatment: co-operative

Panorex

05/28/2013

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

Differential Diagnosis

Classification of the lesion

1)Intrabony or Peripheral?

2)Inflammation, Neoplasm or Cyst?

3)Benign or Malignant?

Peripheral or intrabony?

Our case peripheral Intrabony Mucosal

lesion

+ + -

Bony

expansion

- - + / -

Cortical bone destruction

- - + / -

Peripheral

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

Benign or Malignancy ?

Our case Benign Malignancy

Surface Smooth Smooth Rough

progressive Slow-

progressing Slow Variable

Pain - +/- +/-

mobility

(in palate) Fixed Fixed Fixed

Benign

Working Diagnosis

1) Pleomorphic adenoma 2) Myoepithelioma

3) Fibroma

4) Warthin’s tumor

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

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

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

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

Clinical impression

•

Treatment

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

Treatment Plan

• ^{術式( 102.05.30 ):}

Excision + stent fixation + terudermis repair

Operation under GA

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

Operation under GA

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

Operation under GA

specimen photo record (102.05.30)

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)

4. N.V. 回小港醫院追蹤

Discussion

Pleomorphic Adenoma

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.

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.

Etiology & Pathogenesis

•

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

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)

醫學倫理討論

醫學倫理與全人照護

•

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)

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

1.自主原則(Autonomy)

•

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

•

(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

2.不傷害原則(Non-maleficence)

•

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

•

(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

3.行善原則(Beneficence)

•

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

•

(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

4.公義原則(Justice)

•

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

•

(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

全人照護的定義

•

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

requirements

•

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

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

•

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

Reference

•

•

• Essentials of Oral Pathology, 3rd Edition

Thanks for your attention!!